tag:blogger.com,1999:blog-104853902024-03-07T00:48:31.643-05:00Dalai's PACS Blog<b>PACS:</b>
<br>
1. <i>n. (acronym)</i> <b>P</b>icture <b>A</b>rchiving and <b>C</b>ommunications <b>S</b>ystem. <br>A device or group of devices and associated network components designed to store and retrieve medical images.
<br>
2. <i>n. (acronym)</i> <b>P</b>ain <b>A</b>nd <b>C</b>onstant <b>S</b>uffering.Dalaihttp://www.blogger.com/profile/17775491711029994911noreply@blogger.comBlogger990125tag:blogger.com,1999:blog-10485390.post-87277115932987378722023-05-31T10:45:00.001-04:002023-05-31T10:45:04.588-04:00ChatGPT Writes A Blog Post! (P.S. I don't think the AI takeover is imminent...)<p></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/a/AVvXsEh6RoX1cYY9KmRm7xr1vmIe12pZr1yr_7J5mXwB7fefLMqSkMkNz0guTFnuw3rT3D_in_h_lJETRuZqutMJgXSSPexCJPccn3Stg4g_8i9G5GAkKe6Nbgecuq_vID5TNHGioJMJic7Upy9CXx463lAoXqcon3DRBQRRBiMErZtMuyM4W3yoYQ" style="margin-left: 1em; margin-right: 1em;"><img alt="" data-original-height="534" data-original-width="1216" height="141" src="https://blogger.googleusercontent.com/img/a/AVvXsEh6RoX1cYY9KmRm7xr1vmIe12pZr1yr_7J5mXwB7fefLMqSkMkNz0guTFnuw3rT3D_in_h_lJETRuZqutMJgXSSPexCJPccn3Stg4g_8i9G5GAkKe6Nbgecuq_vID5TNHGioJMJic7Upy9CXx463lAoXqcon3DRBQRRBiMErZtMuyM4W3yoYQ" width="320" /></a></div><br /><p></p><i>ChatGPT prompt: write a blog post for Doctordalai.com<br /></i><br /><p><b><u></u></b></p><blockquote><p><b><u>Unraveling the Mysteries of Modern Medicine: A Journey through the World of Doctordalai.com</u></b></p><p><br /></p><p>Introduction:</p><p>In today's fast-paced world, accessing accurate and reliable medical information is more important than ever. With countless health-related websites available at our fingertips, it can be challenging to discern which sources to trust. However, amidst this vast digital landscape, there shines a beacon of knowledge and expertise: Doctordalai.com. In this blog post, we delve into the fascinating world of Doctordalai.com, exploring its valuable resources and unravelling the mysteries of modern medicine.</p><p><br /></p><p>1. A Trusted Source for Medical Insights:</p><p>Doctordalai.com stands out as a reputable platform that offers a wealth of medical insights. The website is led by a team of highly knowledgeable healthcare professionals who provide reliable and up-to-date information on a range of medical topics. Whether you're seeking information about a specific condition, looking for wellness tips, or wanting to stay informed about the latest medical breakthroughs, Doctordalai.com has you covered.</p><p><br /></p><p>2. Patient Empowerment and Education:</p><p>At the heart of Doctordalai.com is the philosophy of patient empowerment and education. Recognizing the importance of informed decision-making, the website offers comprehensive resources that help individuals understand their health conditions and treatment options. From detailed articles explaining complex medical concepts in layman's terms to patient-friendly guides on navigating the healthcare system, Doctordalai.com equips readers with the knowledge they need to take control of their health.</p><p><br /></p><p>3. Bridging the Gap between Medicine and Technology:</p><p>Doctordalai.com understands the ever-evolving landscape of medicine and technology. With advancements like telemedicine, wearable devices, and artificial intelligence revolutionizing healthcare, Doctordalai.com explores the intersection of medicine and technology, providing insights into how these innovations are shaping the future of healthcare delivery. By staying at the forefront of these developments, Doctordalai.com helps readers make sense of the digital healthcare revolution.</p><p><br /></p><p>4. Expertise That Spans Specialties:</p><p>From cardiology to dermatology, infectious diseases to pediatrics, Doctordalai.com covers a wide range of medical specialties. The website boasts a team of diverse experts who contribute their knowledge and experience, ensuring that readers receive accurate information across various medical domains. This comprehensive approach distinguishes Doctordalai.com as a go-to resource for individuals seeking expert insights regardless of their specific healthcare needs.</p><p><br /></p><p>5. Interactive Community and Engagement:</p><p>Beyond its vast repository of medical knowledge, Doctordalai.com fosters an interactive community of health enthusiasts. The website offers various channels for readers to engage, including comment sections, discussion forums, and even live Q&A sessions with medical professionals. This sense of community not only creates a space for individuals to ask questions and seek advice but also facilitates the exchange of experiences and support among fellow readers.</p><p><br /></p><p>Conclusion:</p><p>In a digital age where accurate medical information is crucial, Doctordalai.com emerges as a trusted and valuable resource. Its commitment to providing reliable medical insights, patient empowerment, bridging the gap between medicine and technology, expertise across specialties, and fostering an interactive community sets it apart from the vast sea of health-related websites. Whether you're a patient, caregiver, or simply a health-conscious individual, Doctordalai.com invites you to embark on a journey of knowledge, empowerment, and discovery within the realm of modern medicine.</p></blockquote><p></p>Dalaihttp://www.blogger.com/profile/17775491711029994911noreply@blogger.com0tag:blogger.com,1999:blog-10485390.post-25412469722725064652022-11-24T14:25:00.012-05:002022-11-27T09:55:01.766-05:00Forgiveness<div>Mrs. Dalai was the love of my life, and I had the great honor of sharing the past 36 years with her. I will miss her more than I can possibly describe.</div><div><br /></div><div>She was often a contradiction in terms. She could be shy, she could be brash. She was retiring, she was outgoing. She felt the presence of God, but she didn’t much like dealing with religion. She was easy to love, and she could be hard to love. But we loved her anyway.</div><div><br /></div><div>Mrs. Dalai and I met on a blind date in 1986. For me, it was love at first sight. For her, it took a little longer. She didn’t know what to do with me. She kept telling me to go away, and I kept coming back. Ultimately, she figured it out. We were married in 1987, not even a year later. It wasn’t a perfect marriage but sometimes we came very close. We had our problems, I guess everyone does, but in the end, they melted into the trivialities they truly were, and we looked forward with great anticipation to our shared future. These were supposed to be our golden years. We had envisioned traveling to the ends of the earth together as long as we were able to do so. That dream was cut short, but at least we managed to visit some unusual places while we were able.</div><div><br /></div><div>My wife lived for her family. Dr. Dolly and Dalai, Jr, always know that she loved you with all her heart, she was fiercely loyal to you, and wanted nothing but the best for you. She was thrilled to see you both thrive and prosper in your chosen professions. (That all goes for Dr. Dolly's husband.) She was very grateful for your making trip after trip to our little town in the Deep South, and particularly for bringing her grandson Dalai III to see her so she could get to know him at least a little bit. The last time she smiled was when Dr. Dolly brought the little guy to see her a few weeks ago. </div><div><br /></div><div>She and I were not perfect parents. We made mistakes, lots of them, but our love for you, her love for you was never in doubt. Always remember that. She wanted to be heard, by you, and by me for that matter, and to have us validate her feelings. Sometimes we didn’t hear her as well as we could have. But we all tried. </div><div><br /></div><div>She loved her extended family. She was devoted to her parents, although her relationship with them was sometimes stormy. Still, as time went on they reached a level of understanding and comfort, and I think she was able to evolve, grow, and blossom under their guidance.</div><div>To her brother... you and she might not have been close as most think of it. You didn’t talk very often over the years. But you shared an unspoken bond. There was no doubt that you would be there for each other. And you were. She loved you dearly, never doubt that. And to her sister-in-law, she loved you like the sister she never had. And you were always there for her as well. </div><div><br /></div><div>Mrs. Dalai truly loved animals. Not just her beloved pups, but all animals. Well, except for snakes. In our travels, we were able to view wildlife in ways that most have never experienced. Birds in the Galapagos Islands, polar bears in Greenland, and her favorite, whales and sea lions and penguins in Antarctica, even snakes in Costa Rica. She would have taken them all home. Except for the snakes. </div><div><br /></div><div>When it came to people, she was trusting, sometimes too much so. She went out of her way to avoid hurting others and often had trouble with the most minor slight from her friends whether intentional or not. But she was quick to forgive. That was the only way she could handle such things. “They didn’t mean it,” she would say. And she would be upset with me for wanting to protect her. </div><div><br /></div><div>She was strong-willed; maybe stubborn is a more appropriate description. That, along with love and prayer, might explain how she survived so long after stopping her chemotherapy. Even when the narcotics dulled her mind, her determination was obvious. If she wanted to get out of bed, she would darn well get out of that bed. If she didn’t want to take her medications, she would spit them out. If she wanted to telephone someone, call them she did. Some of you received some of those barely-coherent calls. The core of her being wanted to reach out to you, even if the details were scrambled. </div><div><br /></div><div>I feel compelled to state the obvious. Cigarettes took her from us. Like her father, she simply could not quit, despite my begging, bargaining, and cajoling and that of her family and friends. We finally learned to live with this horrible habit, as she made it clear that there was no other choice. But she was quick to tell anyone who would listen not to ever start. When she was diagnosed with lung cancer, I asked her point blank if there was anything I could have done to get her to quit. NO. NOTHING. </div><div><br /></div><div>We have all suffered tremendously knowing that she made the conscious decision to stop her cancer treatments. It is so easy to feel that she didn’t love us enough to quit smoking or to continue chemotherapy. It’s easy to feel that she gave up on us and on herself. That isn’t fair. I don’t think she could think beyond the horrible side-effects of her chemotherapy, even though it was working, and could have given her more time with us. Maybe. We’ll never know.</div><div><br /></div><div>Her course after stopping therapy was not what she expected. She thought she would simply fade away, peacefully and quietly. But there was incredible pain, requiring narcotics around the clock to alleviate it. The medications stole most of her personality, as well as her dignity. Surprisingly, or maybe not so much so, she was never really afraid of death. She became weaker and weaker, her connection with reality became more and more tenuous. Her appetite waned. She started wandering and falling. I didn’t react well to her decline. I got frustrated and even angry with her. I guess deep down I thought I could wake her from her reverie if I just spoke loud enough. It didn’t work. The person we loved was only barely there. Until she wasn’t.</div><div><br /></div><div>Losing her cuts off the chance to make amends, to forgive and seek forgiveness. We remember the good times, but it would be foolish to say that she was perfect, because none of us are. I think ultimately she would forgive us for the transgressions we might think about now, real and imagined. That is who she was. Trust me. Even the deepest injuries could be forgotten. Sometimes the worst of these took a while to heal, but heal they did. She just wanted us to hear her, to validate her feelings. </div><div><br /></div><div>Perhaps that's how to best remember her. If she could have verbalized it, she would simply want us to try to hear each other. This was a revelation that has to be lived to be understood. Maybe that’s what she taught me in her last few days on this Earth. Yelling as loud as you can doesn’t guarantee that you will be heard. Understanding can only happen if we are capable of listening. </div><div><br /></div><div>Mrs. Dalai wasn’t perfect, nor are we. Let that be her legacy to all of us. Today, as we lay her to rest, the only thing to remember is the love she felt for us and the love we felt for her. And remember her with love. Her 66 years went by in the blink of an eye. In another brief instant, I’ll be joining her here. I have no doubt that Hank Williams (who is buried nearby) will serenade us when that time comes, and we’ll dance together once again. </div><div><br /></div>Dalaihttp://www.blogger.com/profile/17775491711029994911noreply@blogger.com3tag:blogger.com,1999:blog-10485390.post-75338518971591431282021-11-01T10:50:00.002-04:002021-11-01T10:50:36.503-04:00Requiem for a PACS<p>Just a funny little epilog from the retired guy. I may be gone, but I hear things. Sometimes those things are real and not in my head.</p><p>It seems that the old place has, after a VERY long time, dropped Agfa PACS in favor of...</p><p><br /></p><p>(Drumroll please...)</p><p><br /></p><p>Philips PACS, formerly known as Carestream. One site had been using the "new" Agility/Enterprise/7.0 Agfa version and the other was still with 6.x. Apparently the powers that be found neither worthy of continuation. Agfa wasn't even in the top three selections for replacement.</p><p>The king is dead. Long live the king. </p>Dalaihttp://www.blogger.com/profile/17775491711029994911noreply@blogger.com7tag:blogger.com,1999:blog-10485390.post-84247629140571157522021-09-04T08:20:00.001-04:002021-09-04T08:20:55.604-04:00Cancer<p>I sometimes like to open my posts with a joke. But not this time. There isn't a joke for this.</p><p>Mrs. Dalai has cancer.</p><p>How's that for a kick in the ass? </p><p>I am neither vain nor arrogant enough to think that I could write the ultimate treatise on dealing with a loved one's cancer. There are any number of engaging stories out there on Caring Bridge and the like. You don't want to read a tear-jerker anyway, nor do you want to endure every last boring and/or gory detail. Mrs. Dalai would be very upset with me if I shared all that. Hell, she's probably going to be upset with me for writing this at all. She is a very private person, and does not like any of her personal details floating out there in cyberspace. Unlike me, of course. What I <i>can</i> deliver is a sort of gestalt, a seat-of-the-pants level series of vignettes, of observations, of feelings. Perhaps a few do's and don'ts for friends of those going through such things. In other words, I'm going to start typing and we'll see what comes out. As usual. </p><p>So...Where to start? </p><p>Mrs. Dalai had upper respiratory symptoms periodically throughout the Fall of last year. Naturally, we worried about COVID-19, but we weren't as petrified over the possibility as her then-internist, who wouldn't let her in the door without a negative COVID test. And another one. And ANOTHER one. And even <i>then</i>, he referred her to the ER rather than risk her coming in the office. As you might guess, he is no longer her internist.</p><p>We did finally get an imaging study, over a <i>month</i> after her symptoms began. I was standing in front of the modality monitor as it was acquired, and watched, paralyzed, as the wrenching turn in our lives was painted on the screen in all its grayscale horror. The tech, not grasping what he was seeing, pointed to the obvious and said, "Gee, what's <i>that</i>?" I didn't answer.</p><p>That was the beginning of an odyssey of visits to local clinics and hospitals, and a trip to one of the many Meccas out there. (A different Mecca insisted she come in person in the height of COVID-19 to be assessed, even though her pathology and imaging reports would tell the whole story. We didn't go there.) She went on to have chemo, radiation, several operations, two on an emergent basis, and was hospitalized for an entire month. Being on staff, I was allowed to stay with Mrs. Dalai 24/7, and I did. Aside from the two nights she spent in the Recovery Room, and two nights where I was able to hire a sitter, I was with her almost every moment. I do believe I deserve the Honorary Inpatient Award if there is such a thing. It would probably consist of my name etched onto a well-used bedpan. In red crayon. </p><p>Some observations from the wards:</p><p>Our hospitals had rolled out a very well-known EMR in the months before our sojourn. Not surprisingly, it was an unmitigated disaster. Order sets had been copied and pasted from elsewhere, and nobody knew nothin' about how the damn thing worked. Medications were at best delayed, and probably some were never given. Had I not been there, the wrong meds would have been administered on more than one occasion. Because EMR. </p><p>I don't know how other places do it, but here, the nurses all have their own full-sized computer on Mini-Cooper sized-carts. I guess no one in IT has heard of a laptop or a tablet. Because the EMR rules all, the nurses cannot do anything for their patients without the mammoth computer cart and so they push the monstrosities ahead of them when the enter the room. Thus, the room becomes quickly overcrowded, and the halls themselves are partially blocked by other Mini-Coopers hovering about, waiting their turn. At least they are easy to parallel-park. There has to be a better way to do this. Google Glass, maybe? Nah, too high-tech...</p><p>With a few notable exceptions, the nurses were spectacular. But they were stretched to the limit due to hiring freezes and staff reductions. Many told us they often went home in tears when their shift was over, and quite a few were planning on leaving. That is, those who were not already travellers. Funny how this staffing issue never strikes the C-Suite, nor do salary cuts. </p><p>Up to half of the nurses were not vaccinated. By their own choice. On the Oncology floor. I'll just leave that here for now. </p><p>We had a problem with one of the nurses' stations. It seems that around 3AM, many of the nurses and others dedicated to the welfare of their patients (or not) got bored, and they would have some very LOUD conversations. Since Mrs. Dalai's room was quite close to said station, we would be awakened by the din outside. AT 3AM. I finally had a chat with the Charge Nurse after a few nights of this. She offered to move us to a room down the hall, away from the racket. I responded in my best a$$hole doctor voice (yes, I have one, which I rarely use), "No, thank you, but you WILL be letting everyone know that making noise at 3AM is interfering with patient care and it is not going to happen again." It didn't. </p><p>Administration managed to get in the way of healing as well. My daughter, Dr. Dolly, just had our first grandchild, Dalai III, and we thought seeing him might cheer up Mrs. Dalai. So after receiving clearance from the oncologist (who examined the hospital's newly-revised visitation policy and found it supposedly welcoming) Dolly and her husband tossed their two-week old baby in the frunk of the Tesla (you don't really believe that, do you?) and drove the 12 hours down here to the Deep South. Once in the hospital, they were immediately turned in by do-gooder Nurse Karen on the Oncology Ward who suffered from the vapors and fainted on her divan, clutching her pearls on the way down, at the sight of a...a....BABY ON THE WARD!!!! In the days of COVID!!!!! Now you have to understand, Dr. Dolly got the vaccine while pregnant and actually wrote some of the national policy that guides such behavior. The kid was fine, and was not in any danger whatsoever. But the skittish, prissy nurse at the desk had alerted Administration to this horrific breach, and within 10 minutes, Nurse Ratched, <strike>Administrator of Pain</strike>, I mean Administrator of the Day, arrived at the door. "NO BABIES! IT'S AGAINST POLICY!!!!!" she said with the thin smile you see on people who love to wield power and torture small animals. We protested, explaining the obvious situation. But no. POLICY!!!! doncha know? Nurse Ratched even told my daughter that she should be "home healing" rather than visiting her mom. You can imagine how that went over with Dr. Dolly (who is an ObGYN herself). Funny how Nurse Ratched didn't direct her indignation at her colleagues who had yet to get the COVID-19 vaccine. </p><p>Someday I'll get around to informing the C-Suite of this fine inspiration of health and demonstration of compassion. It might have made a positive difference in Mrs. Dalai's outlook had she been able to hold III a little longer. But...POLICY. As I have found over the years with HIPAA, tortuous, self-serving IT security rules, and other similar things, COVID-19, or any other crisis, can on occasion be used rather nefariously to protect those who either want to avoid doing their job, or wish to dominate others around them. As you know from my previous missives, I cannot stand either mentality. Particularly when the health of my loved ones is impacted.</p><p>In the same vein (vain? vane?)...If you were managing a hospital, would you put the Oncology ward across the hall from the COVID ward? I wouldn't. 'Nuff said.</p><p>Anyway. </p><p>I got really sick of cafeteria food (some of which was occasionally available in the Doctor's Lounge...loved the Oreo chocolate pudding parfaits!) Subway had a sad little outpost within the hospital walls, and that helped, but there are only so many permutations of their ingredients, which I mostly exhausted after a week or so. I did use delivery now and then, but frankly, I wasn't all that hungry, and Mrs. Dalai's taste changed minute by minute. The nurses let me get my own bedding from the Clean Linen room, and I became very adept at making up the couch into a relatively comfortable bed. I became known as the one doctor in the hospital who would help them make the patient's bed. I got good at that, too. </p><p>There's more, of course, but I've probably already overstepped my bounds on certain issues. So sorry. I'm usually known for my restraint. Just ask certain PACS vendors. </p><p>Let me say a few words to those who are supporting a friend or relative with cancer, or really, any other serious malady, and supporting the patient's caregiver(s) as well. I should preface this by emphasizing that every situation is different. Each patient and each family member or caregiver has very individual wants and needs. What I say about me might not apply to someone else. </p><p>Most of our friends have asked repeatedly, "What can we do to help?" The honest answer is often that<i> I don't know</i>. I am more grateful for these offers than you could ever imagine, and I hope my friends don't take offense when I can't really respond. Cook something? Sure...wish I could have specified what would taste good when nothing struck Mrs. Dalai as the least bit appetizing. Come visit? She didn't want people seeing her at her worst. And so on. So I began to simply respond, truthfully, that what we really needed most was everyone's prayers. She has been the beneficiary of an amazing outpouring of good wishes and is on prayer-lists that literally span the globe. Yes, I <i>do</i> believe in the power of prayer. Very much so. If you also believe, please take a second and say a prayer for her. If you don't, do it anyway. </p><p>The concern was at times overwhelming, and this is where I might offer some advice. There were days while she was in the hospital that I spent an hour texting the daily "Mrs. Dalai Report" to the dozens of people asking about her. In fact, she sometimes looked over at me pecking away on Messenger and asked, "Are you on that damn phone AGAIN?" "Yes, dear, but for a good cause..." At first, I would try to individualize the text, but I later resigned myself to copying and pasting. On one particularly stressful day, I got lazy and sent a group text in a manner Apple assured me would not reveal the recipients to each other (it did anyway) and I accidentally pasted in the more detailed medical version rather than the streamlined USA Today-level prose. No big deal, but I learned my lesson. Back to copying and pasting.</p><p>Oh, yes, the advice...in essence, don't let your anxieties get the best of you. Which is a nice way of saying, don't call or text <i>too</i> often (like multiple times per day) and don't freak out if you don't hear something in some particular time-frame. If I was late with the daily report, several people would text (or call) fearing that something bad (worse?) had happened. But that only delays communications further. Rather like the ER phoning to ask why you haven't read Mrs. Jones' scan and in the process keeping you from reading it. I know they all meant well (except for the ER) and the concern is again much appreciated. But...</p><p>Believe it or not, there can be a negative side to caring. We have several acquaintances (I won't call them friends) who <i>MUST</i> KNOW every last gory detail of what's going on. And then they <i>MUST</i> SHARE these details with everyone else in their coven, I mean circle. I liken this to a bunch of kids trading baseball cards. ("I'll swap you Mr. McGillicuddy's splenectomy for Mrs. Smith's gallstones...") At the extreme, someone continuously texted me with a barrage of increasingly granular inquiries and then capped it off with the statement, "I have SO MANY questions!!!" I'm sorry, but that goes beyond caring and enters the realm of prying and even nagging. Please just allow me to give out the facts I think are needed, and let it go at that; in other words, have mercy on me and Mrs. Dalai. I did my best to keep these people happy and at arm's length, but it wasn't easy. We actually tried to hide the news from several such folk, attempting to keep Mrs. Dalai from becoming the topic of conversation around our little town, but of course that didn't work. I had occasion to discuss this with the hospital chaplain one day, and he analyzed it in this manner: "These people are very needy in their own way. They need your tragedy to feel better about themselves. Don't feed them, particularly while you and Mrs. Dalai are in genuine need yourselves." Spot on, Padre. Spot on. </p><p>And although I assume the best intentions, I <i>don't</i> need to hear about Cousin Schmuly, the best oncologist ever to grace the halls of some Mecca whom just <i>everyone</i> in the family consults for every funny looking freckle. We have a wonderful team of physicians here and we trust them 100%. And no, I'm <i>not</i> one of them. I do my best to avoid looking at her studies at all. I've still got PTSD from the slow-reveal of the initial image. </p><p>I can think of two questions that were asked, one innocently, one not so much, that should NEVER be uttered in these circumstance. The innocent question is one you might be surprised to learn has the unintended potential to deeply wound, and that is simply, "What is her prognosis?" That is a question one should NOT ask. EVER. Unlike the medical shows on television, there are no hard and fast answers. We can quote the odds, or the chances, or whatever, but remember, statistics do not apply to the individual. (Mrs. Dalai's oncologist actually went so far as to warn us against looking at those numbers.) Every day is another day, every day is precious, and we all take this journey through life one day at a time. We are not cartons of milk, only God can see the expiration dates stamped on our foreheads. </p><p>The other question, which was asked maybe innocently and maybe not by an acquaintance who in her late 70's is still quite concerned with body image was, "How much weight have you lost from Chemo?" Fortunately that question was posed in a phone call, and I wasn't on the line. Had I been, I would have jumped straight through the ether and throttled the other party. How vain and superficial can you get? Don't answer that...</p><p>In spite of all the love and support we have received, there is some degree of loneliness inherent in having a chronic illness. Mrs. Dalai often does not feel well enough to go out, but that's happening less and less. Still, she can feel a bit isolated. Hey, would any of you want to be locked up with <i>me</i> when you aren't feeling well? Or even if you ARE feeling well? Blessings to our friends who put up with our periodic cancellations of plans and such. </p><p>I think people often don't know how to be around someone with cancer, or other chronic illness. That one's easy. Just be yourself, let them be themselves. They are the same person they always were. They might be more fatigued, perhaps more irritable if they are experiencing pain. But they are still the person you know and love. </p><p>I wish I had something profound with which to end this little treatise. I really don't. How about "Cancer is bad!"? Does that work? Not really. How about the more optimistic "They are making great strides in treatment!"? That's a little better. And it's true. But the word "cancer" will always evoke feelings of dread in all of us. I'll never, ever, EVER get used to Mrs. Dalai's nonchalant tone when she says, "I have cancer," or something similar. It's a dagger through my heart. Every. Single. Time. </p><p>This is a long haul, for me and for her, but what was inevitably fatal when I was a medical student back in the days of stone knives and bearskins is no longer so. There are no guarantees, but for many, cancer can be cured, or at least kept at bay for a very long time. It seems that we don't use the word "cure" so much; rather, the favored term these days is Complete Remission, or CR. Please keep Mrs. Dalai in your prayers with that in mind. </p><p>And if you smoke, stop. Right now. Today. NOW. Please. Oh, and take the damn COVID-19 vaccine TODAY if you haven't yet done so. Do it. Don't argue, don't quote any bullshit you've heard on Facebook or some other cesspool. JUST GET THE DAMN VACCINE NOW. We've had ours (and she's had the booster), with zero ill-effects. Please get it, not for yourself, but for the others you might save by not transmitting the virus. There are a lot of immune-compromised folks out there who will thank you. Starting with Mrs. Dalai. </p>Dalaihttp://www.blogger.com/profile/17775491711029994911noreply@blogger.com5tag:blogger.com,1999:blog-10485390.post-88915595399273430462021-04-01T09:18:00.008-04:002021-05-24T14:14:49.813-04:00April Fool’s Day<p>Long story. I don’t have anything funny to say at the moment. Aside from the birth of my first grandchild last month, 2021 has made 2020 look like the most wonderful year ever. </p><p>Stay well, my friends. I’ll get back to writing eventually when things are calm and contracts don’t restrict. </p><p>In the meantime, if you smoke, quit. NOW. You <b><i>Can</i></b> Do It!</p>Dalaihttp://www.blogger.com/profile/17775491711029994911noreply@blogger.com0tag:blogger.com,1999:blog-10485390.post-8867072161312209442020-09-22T15:57:00.002-04:002020-09-25T11:40:39.957-04:00Incompetence, Incompetents, and Incontinence<div class="separator" style="clear: both; text-align: left;">I clearly have neglected my poor blog. There have been very few new posts in the past year. I'll chalk it up to some patois of melancholy, sloth, feeling stuck in Purgatory, SARS-CoV-2 (mainly the fear of it...we have remained free of illness, thank Heavens!), and maybe a touch of writer's block. But even in its tepid twilight of quasi-existence, people do still read my various random thoughts. I know because I continue to track such things. </div><div class="separator" style="clear: both; text-align: left;"><br /></div><div class="separator" style="clear: both; text-align: left;">It has come to my attention that an <a href="https://doctordalai.blogspot.com/2019/06/it-still-doesnt-get-it.html" rel="nofollow" target="_blank">old post</a> from over a year ago has taken the fancy of some IT folk:</div><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: center;"><br /></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEju4joRtY1nCrMeQY7Kdr-LEoJxoGOuM6RmGq3MuKNs62IPKV2xe_4nyE3kPDdE8oxzqheuawf7QxNU82xc1fAWnsIBLInsZYlyzWZP-3F54E2rRWIV1xO4jjWgrWG95hC7d2Im/s1862/Screen+Shot+2020-09-22+at+12.34.03+PM.png" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1862" data-original-width="860" height="640" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEju4joRtY1nCrMeQY7Kdr-LEoJxoGOuM6RmGq3MuKNs62IPKV2xe_4nyE3kPDdE8oxzqheuawf7QxNU82xc1fAWnsIBLInsZYlyzWZP-3F54E2rRWIV1xO4jjWgrWG95hC7d2Im/w296-h640/Screen+Shot+2020-09-22+at+12.34.03+PM.png" width="296" /></a></div><br /><div>In fact, word has reached me that they were not amused. "Dalai is calling us INCOMPETENT!!!" they were heard to say. </div><div><br /></div><div>Well, as Oscar Wilde once remarked, "There is only one thing in life worse than being talked about, and that is <i>not</i> being talked about." I suppose that applies to me as much as my new friends. But let's have a look at this.</div><div><br /></div><div>I've scanned the post over and over, and nary a mention do I find of the word "incompetent" or any variation thereof. Nothing of the sort. Nada. Bupkiss. I <i>did</i> say, and I quote myself: </div><div><br /></div><div></div><blockquote><div>"IT has not a clue as to Radiology workflow, not to mention mission criticality."</div><div></div></blockquote><div>and</div><div></div><blockquote><div>"BECAUSE THEY DON'T UNDERSTAND WHAT WE DO OR HOW WE DO IT but they make decisions about our workflow anyway."</div><div></div></blockquote><div><br /></div><div>See? No mention of <i>incompetence</i>, or <i>incompetents</i>, whatsoever. Or even <i>incontinence</i>. </div><div><br /></div><div>What I AM saying is that there is a fundamental disconnect, which sadly, my blog has not been able to repair over its 15-year existence. As per Dalai's First Law (<i>"The PACS IS The Radiology Department"</i>) we are no better than our machinery. To see the examinations we are here to interpret, the PACS has to work. And it's deeper than that. My time in Africa has taught me that we are incredibly dependent upon infrastructure, not just for the PACS to work, but for all the other stuff as well. It's a real problem when, for example, the power goes out several times per day. Computers and scanners do not thrive in that environment. What if you can't get a part for your CT because Customs won't let it out of holding because, well, just because? Or the security guy at the airport wants you to open a Molybdenum generator? <i>All the way open</i>. (Yes, that really happened. No, it didn't get opened.)</div><div><br /></div><div>The situation discussed in the original post shows not incompetence, but perhaps ignorance, and I mean that in the nice way. (I could have said <i>arrogance</i>, but I didn't.) The best-case scenario is that IT doesn't grasp that being without the integrated transcription, and having to dial-in on EVERY SINGLE REPORT over four hours is a huge impediment to patient-care, and patient care is the thing we are ALL here to provide. And we all need each other's help to make that happen. </div><div><br /></div><div>An analogy might be in order. Suppose I'm the Chief Electrician for the Enterprise (no, not <i>that</i> one), and I find that there is some wiring in the data-center that is in need of routine maintenance. I could say, "Sorry, boys and girls, gotta do this NOW and take down half your servers during the busiest time of the day, but here's an extension cord so you can keep <i>some</i> of them running..." OR, I could say, "Sorry, boys and girls, we have this wiring upgrade that must be done soon. How can we work together to make this happen with the least impact upon patient-care?"</div><div><br /></div><div>This isn't rocket-science, folks. It's simple common sense and us all trying to be good team-players with the goal of helping our real "customers," the patients. </div><div><br /></div><div>I think we are all competent enough to do that. </div>Dalaihttp://www.blogger.com/profile/17775491711029994911noreply@blogger.com0tag:blogger.com,1999:blog-10485390.post-49382515656793704912020-08-22T12:57:00.002-04:002020-08-22T12:57:52.865-04:00Hi, General Electric!<p> Looking for something? Please let me know if I may be of service!</p><p><br /></p><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiZlZxdSR-GMnlGlOn3cJ0pt1RUgrSgX3cpe4iJZwX_Hd2vPoPkea9xax2nQaFoRkQurVAjteKikuUzyiClfn46ua0_n6AxU1WFZSv6K7_IYvpiexXo6dp_f_3QGf_tNUB95Xmp/s2196/Screen+Shot+2020-08-22+at+12.56.06+PM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1008" data-original-width="2196" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiZlZxdSR-GMnlGlOn3cJ0pt1RUgrSgX3cpe4iJZwX_Hd2vPoPkea9xax2nQaFoRkQurVAjteKikuUzyiClfn46ua0_n6AxU1WFZSv6K7_IYvpiexXo6dp_f_3QGf_tNUB95Xmp/s640/Screen+Shot+2020-08-22+at+12.56.06+PM.png" width="640" /></a></div><p><br /></p>Dalaihttp://www.blogger.com/profile/17775491711029994911noreply@blogger.com0tag:blogger.com,1999:blog-10485390.post-53536445777786752812020-04-01T20:51:00.000-04:002020-04-01T20:51:46.146-04:00Dalai's Annual April Fool's Day Post<br /><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi7mB7SnVXZOkvImsMm6Jml-S1L5avaWu0R3cSZeL7jyN_VUkSFOlPK2JRQB_SFaXWNm-QGJHD1KwNicESEhkRCb7kWPiAkzEQmxavXGbyNKJW-e-WIEVB_vfGkOT-oCZ0b2Vw2/" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="480" data-original-width="640" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi7mB7SnVXZOkvImsMm6Jml-S1L5avaWu0R3cSZeL7jyN_VUkSFOlPK2JRQB_SFaXWNm-QGJHD1KwNicESEhkRCb7kWPiAkzEQmxavXGbyNKJW-e-WIEVB_vfGkOT-oCZ0b2Vw2/s320/Spock+April.jpg" width="320" /></a></div>Dalaihttp://www.blogger.com/profile/17775491711029994911noreply@blogger.com0tag:blogger.com,1999:blog-10485390.post-70858977513929555642019-06-26T17:22:00.001-04:002019-06-27T07:32:30.460-04:00You Can't Hide Your Bottom Line<a href="https://draft.blogger.com/blogger.g?blogID=10485390" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"></a><i>Dalai's note: There are a number of discussions on Aunt Minnie concerning the acquisition of radiology groups by predatory venture capital operations. And so, with apologies to the Eagles....</i><br />
<br />
<blockquote>
Greedy rads just never get the message<br />
That guys in suits are not their new best friends <br />
Big Venture Cap <br />
And they won’t have to worry <br />
They’ll dump their overhead and drive a Benz <br />
Late at night, the reading room gets lonely<br />
I guess selling out young partners has its price<br />
And it breaks your heart to see your talents going <br />
To a predator with soul as cold as ice. <br />
So you tell the junior kids that you’ll protect them <br />
From the guys in suits that want to take you down <br />
But they know that you’re lyin’ as your speakin’ <br />
That you’re looking for a payoff to come ‘round <br />
<br />
<br />
<i>You can’t hide your bottom line <br />
And you’ll never get that big gold mine <br />
No one buys your story line <br />
There ain’t no way to hide your bottom line<br /> </i>
<br />
<a href="https://draft.blogger.com/blogger.g?blogID=10485390" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"></a><br />
In an office park downtown the beans are counting <br />
Finding RVU’s that they are gonna steal <br />
And you sign right on the line anticipating <br />
That you’ll fool them and prevail in this deal <br />
The younger guys think you’re in this together <br />
That you’re only in this for a short while <br />
And you swear that soon you’re going to get a letter <br />
That shows that everybody gets a pile <br />
<br />
<br />
<i>You can’t hide your bottom line <br />
And you never got that big gold mine <br />
No one buys your story line <br />
There ain’t no way to hide your bottom line </i>
<br />
<br />
You stand up and drink a hot one from the Keurig <br />
And stare at that endless list there on the PACS <br />
Another night of thinking you’re the bigwig <br />
Just you would know who’s gonna get the ax <br />
You wonder how you ever got so greedy <br />
Big house and cars and snotty private schools <br />
You thought you’d be let off for being needy? <br />
You’ve got to know you look just like a fool <br />
My oh my, you sure know how to wreck things <br />
You set it up so well so carefully <br />
Ain’t it funny how your new gig doesn’t change things <br />
You’re still the same old jerk you used to be <br />
<br />
<br />
<i>You can’t hide your bottom line <br />
And you never got that big gold mine <br />
No one buys your story line <br />
There ain’t no way to hide your bottom line <br />
There ain’t no way to hide your bottom line <br />
Doctor, you can’t hide your bottom line</i> </blockquote>
Dalaihttp://www.blogger.com/profile/17775491711029994911noreply@blogger.com1tag:blogger.com,1999:blog-10485390.post-5218555777962012902019-06-25T09:05:00.002-04:002019-06-27T07:36:23.597-04:00To My Friends In India Who Happen To Be Affiliate Marketers...<a href="https://draft.blogger.com/blogger.g?blogID=10485390" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"></a>I've never hidden the fact that I track the readership of this blog. It's not that I get all that much traffic, but I do get a big thrill knowing that I have reached people from around the world. Interestingly, in the past few days, DoctorDalai.com has been viewed several thousand times by someone in the Czech Republic. To that poor fellow, I can only say, "Děkuji!" <br />
<br />
But as the title above might suggest, I continue to be plagued by "comments" that invariably originate from India. I put "comments" in quotes because these "comments" have nothing to do with the post they "comment" on, but rather are thinly-veiled attempts at SPAM, pushing everything from gambling websites to taxi-services in England. Last night, I even got one from an AI company:<br />
<br />
<br />
<blockquote>
(AI Company) has left a new comment on your post "How IBM Watson Overpromised and Underdelivered on your post "How IBM Watson Overpromised and Underdelivered on ..."":
(AI Company) has developed a Interactive Streaming and AI Platform for medical imaging. We own a intellectual property and patent to a new cloud technology platform in medical imaging. At (AI Company) technology and patents covers secure and highly available cloud storage of medical imaging using supercomputing clusters, advanced 2D and 3D diagnostic visualization of medical images using GPU clusters, and the use of Artificial Intelligence in computer aided detection of medical images using genetic algorithm or convolution nueral networks.
<br />
<br />
Link: Interactive Streaming Artificial Intelligence Platform </blockquote>
Misspellings are theirs.
Here is the tracking information on this "comment":<br />
<br />
<blockquote class="tr_bq">
<span style="background-color: #f3f7fa; font-family: "open_sansregular" , "arial" , "helvetica neue" , "helvetica" , sans-serif; white-space: nowrap;">Jubilee Hills, India, </span><span class="hostname-ip" style="background-color: #f3f7fa; font-family: "open_sansregular" , "arial" , "helvetica neue" , "helvetica" , sans-serif; margin: 0px; padding: 0px; white-space: nowrap;"><span class="hostname" style="color: #bb2222; display: inline-block; font-weight: bold; margin: 0px 0px 1px; padding: 0px;">Atria Convergence Technologies Pvt. Ltd. Broadband</span> <span class="ip-address-small" style="font-family: monospace; font-weight: bold; margin: 0px; padding: 0px;">49.204.222.47</span></span></blockquote>
<span class="hostname-ip" style="background-color: #f3f7fa; font-family: "open_sansregular" , "arial" , "helvetica neue" , "helvetica" , sans-serif; font-size: 12px; margin: 0px; padding: 0px; white-space: nowrap;"><span class="ip-address-small" style="font-family: monospace; font-size: 11px; font-weight: bold; margin: 0px; padding: 0px;"><br /></span></span>
And to make the morning complete, I got another such SPAM comment later on:<br />
<div>
<br /></div>
<blockquote>
Unknown: 7:38 AM (59 minutes ago)to me
<br />
Unknown has left a new comment on your post "Driving "Miss Taxi"":
<br />
<br />
its very good and nice blog
<br />
<br />
taxi park<br />
bromley superb airport transfer taxi<br />
minicabs bromley </blockquote>
Here's the tracking information on this "comment":<br />
<br />
<blockquote class="tr_bq">
<span style="background-color: #f3f7fa; font-family: "open_sansregular" , "arial" , "helvetica neue" , "helvetica" , sans-serif; white-space: nowrap;">Chennai, Tamil Nadu, India, </span><span class="hostname-ip" style="background-color: #f3f7fa; font-family: "open_sansregular" , "arial" , "helvetica neue" , "helvetica" , sans-serif; margin: 0px; padding: 0px; white-space: nowrap;"><span class="hostname" style="color: #bb2222; display: inline-block; font-weight: bold; margin: 0px 0px 1px; padding: 0px;">Airtel Broadband</span> <span class="ip-address-small" style="font-family: monospace; font-weight: bold; margin: 0px; padding: 0px;">171.60.225.12</span> <a class="visitor-label visitor-alert-disabled add-label" data-horizontal-offset="-3" data-ip="171.60.225.12" data-jq-dropdown="#add-visitor-label" data-target="uuid-ip" data-uuid="617438243D804FAE51DAC60B8E8FDA58" href="https://statcounter.com/p10501808/add-ip-address-label/?ip_address=171.60.225.12&return_url=%2Fp10501808%2Fpath%2F" style="background: url("data:image/svg+xml,%3Csvg xmlns=%27http://www.w3.org/2000/svg%27 xml:space=%27preserve%27 viewBox=%270 0 23 13%27 height=%2713%27 width=%2723%27 version=%271.1%27 y=%270px%27 x=%270px%27%3E%3Cpath d=%27m19.875%2C12.5c1.4498%2C0%2C2.625-1.1513%2C2.625-2.5714v-6.8572c0-1.4201-1.175-2.5714-2.625-2.5714h-14.125l-5.25%2C6.1033%2C5.25%2C5.8967h14.125z%27 stroke=%27%238bb1d8%27 stroke-width=%271%27 fill=%27%23e7eff5%27/%3E%3Cpath d=%27m10.5%2C6.5c0%2C1.6569-1.3431%2C3-3%2C3s-3-1.3431-3-3%2C1.3431-3%2C3-3%2C3%2C1.3431%2C3%2C3z%27 stroke=%27%238bb1d8%27 stroke-width=%271%27 fill=%27white%27/%3E%3Cpath d=%27m13%2C5%2C7%2C0%27 stroke=%27%238bb1d8%27 stroke-width=%271%27 fill=%27none%27/%3E%3Cpath d=%27m13%2C8%2C7%2C0%27 stroke=%27%238bb1d8%27 stroke-width=%271%27 fill=%27none%27/%3E%3C/svg%3E") left 2px no-repeat transparent; color: #2e3c4c; display: inline-block; height: 16px; margin: 0px; padding: 0px; text-decoration-line: none; width: 23px;"> </a></span></blockquote>
<br />
Here's what's going on. There is a practice out there in the Aether called "Affiliate Marketing". The <a href="https://en.wikipedia.org/wiki/Affiliate_marketing">Wikipedia</a> article is rather long and convoluted, but the gist of it is this:<br />
<br />
<blockquote class="tr_bq">
<b style="background-color: white; color: #222222; font-family: sans-serif; font-size: 14px;">Affiliate marketing</b><span style="background-color: white; color: #222222; font-family: sans-serif; font-size: 14px;"> is a type of </span><a class="mw-redirect" href="https://en.wikipedia.org/wiki/Performance-based_marketing" style="background: none rgb(255, 255, 255); color: #0b0080; font-family: sans-serif; font-size: 14px; text-decoration-line: none;" title="Performance-based marketing">performance-based marketing</a><span style="background-color: white; color: #222222; font-family: sans-serif; font-size: 14px;"> in which a business rewards one or more </span><a href="https://en.wikipedia.org/wiki/Affiliate_(commerce)" style="background: none rgb(255, 255, 255); color: #0b0080; font-family: sans-serif; font-size: 14px; text-decoration-line: none;" title="Affiliate (commerce)">affiliates</a><span style="background-color: white; color: #222222; font-family: sans-serif; font-size: 14px;"> for each visitor or customer brought by the affiliate's own </span><a href="https://en.wikipedia.org/wiki/Marketing" style="background: none rgb(255, 255, 255); color: #0b0080; font-family: sans-serif; font-size: 14px; text-decoration-line: none;" title="Marketing">marketing</a> <span style="background-color: white; color: #222222; font-family: sans-serif; font-size: 14px;">efforts.</span><sup class="reference" id="cite_ref-1" style="background-color: white; color: #222222; font-family: sans-serif; font-size: 11.2px; line-height: 1; unicode-bidi: isolate; white-space: nowrap;"><a href="https://en.wikipedia.org/wiki/Affiliate_marketing#cite_note-1" style="background: none; color: #0b0080; text-decoration-line: none;">[1]</a></sup><sup class="reference" id="cite_ref-2" style="background-color: white; color: #222222; font-family: sans-serif; font-size: 11.2px; line-height: 1; unicode-bidi: isolate; white-space: nowrap;"><a href="https://en.wikipedia.org/wiki/Affiliate_marketing#cite_note-2" style="background: none; color: #0b0080; text-decoration-line: none;">[2]</a></sup><sup class="reference" id="cite_ref-3" style="background-color: white; color: #222222; font-family: sans-serif; font-size: 11.2px; line-height: 1; unicode-bidi: isolate; white-space: nowrap;"><a href="https://en.wikipedia.org/wiki/Affiliate_marketing#cite_note-3" style="background: none; color: #0b0080; text-decoration-line: none;">[3]</a></sup><sup class="reference" id="cite_ref-4" style="background-color: white; color: #222222; font-family: sans-serif; font-size: 11.2px; line-height: 1; unicode-bidi: isolate; white-space: nowrap;"><a href="https://en.wikipedia.org/wiki/Affiliate_marketing#cite_note-4" style="background: none; color: #0b0080; text-decoration-line: none;">[4]</a></sup><sup class="reference" id="cite_ref-5" style="background-color: white; color: #222222; font-family: sans-serif; font-size: 11.2px; line-height: 1; unicode-bidi: isolate; white-space: nowrap;"><a href="https://en.wikipedia.org/wiki/Affiliate_marketing#cite_note-5" style="background: none; color: #0b0080; text-decoration-line: none;">[5]</a></sup></blockquote>
<br />
More simply:<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiwOZ2RSpC6ErA4p-xjrRsCAxUCczFeJkeRwRhVwHJ6PagIFHp-Bt42NklwPBFGGWrOzmCCejtLcn5ikApmKi9BQqnZFfhAw9TO1_w3jcqrgq4YKBGb9059_AycnzasrSmQMaYh/s1600/affiliate-marketing.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1000" data-original-width="1500" height="266" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiwOZ2RSpC6ErA4p-xjrRsCAxUCczFeJkeRwRhVwHJ6PagIFHp-Bt42NklwPBFGGWrOzmCCejtLcn5ikApmKi9BQqnZFfhAw9TO1_w3jcqrgq4YKBGb9059_AycnzasrSmQMaYh/s400/affiliate-marketing.png" width="400" /></a></div>
<br />
Affiliate marketing is yet another way for less-than-industrious folks to insert themselves into someone else's revenue stream. Kinda like Enron for dummies.<br />
<br />
In the case of my "commenters", they operate under the belief that I will allow their "comments" to be published to my blog, which I DO NOT. If I were to allow it, my innocent readers would then click the links, and the "commenter" would then get some small pittance for each click. That's how this works. Sometimes the "comments" are placed manually, sometimes by 'bots that key on to one word in the blog-post, such as you see above.<br />
<br />
Here's what happens when I'm informed about one of these SPAM "comments". First, Blogger.com, the platform where this blog resides, allows me to label the comment as SPAM and keep it from publishing, and that is what I do with each one. Second, I DO click the links, and then contact each and every business involved. I make sure the owner of said business knows that they are wasting their money on the (presumably) cheap marketing, that this is really BAD advertising which brings them nothing but animosity.<br />
<br />
I did have one business owner admit to using this bottom-feeder practice, and promised to fire his "affiliate". And he promised that AGAIN when I got another barrage of "comments" leading to his site that originated in, you guessed it, India.<br />
<br />
I don't know if it is a language or a cultural barrier, but every single affiliate marketing blog comment spammer I've encountered has come from India. Perhaps this sort of thing is acceptable in that market. I hate to be the one to tell you guys, but it is NOT appreciated here. Not one little bit.<br />
<br />
So cut it out. Now. CEASE AND DESIST. You won't make one Rupee from this, and you will likely be removed as an affiliate from the company you try to dump on my blog. Stop this nonsense and find a REAL job.<br />
<br />
Thank you.<br />
<br />
<a href="https://draft.blogger.com/blogger.g?blogID=10485390" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"></a>Addendum:<br />
<br />
I got ANOTHER spam from the AI company, and so I'll reveal its name: <a href="http://lifevoxel.com/">http://lifevoxel.com/</a> One has to worry about a place that has to use this bottom-feeder form of advertising.<br />
<br />Dalaihttp://www.blogger.com/profile/17775491711029994911noreply@blogger.com2tag:blogger.com,1999:blog-10485390.post-11865570202643981372019-06-03T13:50:00.001-04:002019-06-03T13:51:44.577-04:00IT STILL Doesn't Get It...<br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgX-QQgtHLt0dbUqvxbituVprfLP9MP_6e3nvExVrRdckq_F6YZ7_mSLM7gSzgI8dKseiQm_74s5Ke-Bkyre_du-mr_S5vCbXmqCeOrN0cZ4A43smmAuh_znXkbYtZw2_xLGaAf/s1600/headinsand.jpeg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="167" data-original-width="302" height="221" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgX-QQgtHLt0dbUqvxbituVprfLP9MP_6e3nvExVrRdckq_F6YZ7_mSLM7gSzgI8dKseiQm_74s5Ke-Bkyre_du-mr_S5vCbXmqCeOrN0cZ4A43smmAuh_znXkbYtZw2_xLGaAf/s400/headinsand.jpeg" width="400" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Image courtesy msbmax.com</td></tr>
</tbody></table>
<br />
From the IT folks today...<br />
<br />
<blockquote class="tr_bq" style="background-color: white; font-family: Arial, Helvetica, sans-serif; font-size: small;">
<span style="color: #222222;">Good morning,<br /> Due to the Data Center move to the new Data Center, Radiology Dictation will be down tomorrow starting at 11am.<br /> During this time, radiologists will need to:<br /><br />1, dial 800-xxx-xxxx<br />2, enter site #<br />3, enter dictation ID<br />4, enter work type<br />5, enter 2 to dictate<br /><br />The Medical Transcriptionists can log into the website</span><span style="color: #222222;"> to listen the job and still type reports in.</span><br />
<span style="color: #222222;">Please check this ahead of time to not delay patient care.</span><br />
<br />
<span style="color: #222222;">We expect this to take 3-4 hours to get things up and running and back to normal.</span><br />
<br />
<br />
<span style="color: #1f497d; font-family: "cambria math" , serif;">Warm Regards,</span><span style="color: #1f497d; font-family: "cambria math" , serif;"> </span><span style="color: #1f497d; font-family: "cambria math" , serif;"><br /></span><span style="color: #1f497d; font-family: "cambria math" , serif;">Systems Analyst</span></blockquote>
<br />
At least the PACS itself isn't affected. At least I don't <i>think</i> it is.<br />
<br />
Here we see the same old thing I've been writing about since dinosaurs roamed the earth. IT has not a clue as to Radiology workflow, not to mention mission criticality. To fall back on DIAL-IN dictation for four of the busiest hours of the day will spell Disaster with a Capital D. Would it occur to the powers-that-be to do this at night? No. Would it occur to the powers-that-be to set up some sort of mirror system or back-up server? No. BECAUSE THEY DON'T UNDERSTAND WHAT WE DO OR HOW WE DO IT but they make decisions about our workflow anyway.<br />
<br />
No doubt this won't go smoothly, but after the requisite grousing, things will go back to where they were, and nothing at all will change.<br />
<br />
Guaranteed.<br />
<br />
<br />
<br />Dalaihttp://www.blogger.com/profile/17775491711029994911noreply@blogger.com1tag:blogger.com,1999:blog-10485390.post-15315242259856503392019-05-28T15:27:00.000-04:002019-05-28T15:28:53.145-04:00Some Amusing Musings About AI<div>
Let us begin with a quote from Yogi Berra:<br />
<br />
<blockquote class="tr_bq">
“It's tough to make predictions, especially about the future.”</blockquote>
</div>
<div>
<br /></div>
Yes, round and round and round we go, and where we stop, nobody knows. The contentious AI discussions on Aunt Minnie continue <i>ad nauseum</i>.<br />
<br />
We've been having this very same discussion for YEARS now, with no real change, no resolution, no obvious final answer. And every time Google or some other NON-physician comes up with an algorithm they CLAIM will outdo a radiologist in detecting something somewhere on someone's scan, the sky is immediately declared to be falling. I'm beginning to wonder if I'm caught up in some Groundhog Day remake, where the nightmare won't end until Andie MacDowell falls in love with me (don't tell Mrs. Dalai!) Alternatively, I wonder if I've been trapped in an HGTV marathon wherein every episode has the same 3-act play:<br />
<ul>
<li>AI can identify a cat picture, so we're doomed </li>
<li>Self-driving cars kill people, who are just as dead as if they had been killed by a drunk driver but Progress! </li>
<li>You can't sue the computer...what would you get? Transistors? But the lawyers will find a way anyway. </li>
</ul>
I'll repeat what I have said from Day One of this discussion: <br />
<ul>
<li>AI is a TOOL to be used to help radiologists help patients. This is the mantra of every HEALTHCARE company in that space. Google, by the way, is NOT a healthcare company. </li>
<li>We radiologists need to be at the forefront of AI development, so it will do what we need it to do, not what some geek from Google tells us it needs to do. </li>
<li>AI will NOT replace radiologists in the working lifetime of anyone reading this. </li>
</ul>
The rest is commentary, gibberish, or both. <br />
<br />
Trust me, children, there are things out there that have a far greater likelihood of disrupting your livelihood, such as corporate takeovers, intergroup squabbling, intragroup squabbling, plaintiff whores, bean-counters, rogue administrators, VC entrepreneurs, gossiping physicians, and others too numerous to list. AI is so far down that list as to be a non-issue. <br />
<br />
I have begged you all to look at AI through the lens of how it could be used to do what you do better. That would be far more productive than this constant pity-party. <br />
<br />
Think about it. Dalaihttp://www.blogger.com/profile/17775491711029994911noreply@blogger.com1tag:blogger.com,1999:blog-10485390.post-12300749701680584222019-05-17T16:26:00.001-04:002019-05-17T16:26:24.009-04:00Generalized Anxiety?<div class="separator" style="clear: both; text-align: center;">
<br /></div>
<div class="separator" style="clear: both; text-align: center;">
<br /></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgcf2jc2SL3ybDLhkGnJs0cg1jsyHQa2liFRM9kTSUJuwI7WNXOOfFhGtj0UybX_Nbi2nteeqLbzoP43CQIiVuExbwV6fQ6-7kXrNdZF6j3M0s8rMOFTB7zqNKPwwdmoV7uGJ7z/s1600/anxitey.gif" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="480" data-original-width="378" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgcf2jc2SL3ybDLhkGnJs0cg1jsyHQa2liFRM9kTSUJuwI7WNXOOfFhGtj0UybX_Nbi2nteeqLbzoP43CQIiVuExbwV6fQ6-7kXrNdZF6j3M0s8rMOFTB7zqNKPwwdmoV7uGJ7z/s320/anxitey.gif" width="252" /></a></div>
<br />
<br />
Just a quickie post.<br />
<br />
In reviewing the blog's activity, I'm noticing a yuuuuuuggge increase in the number of hits looking for information about GE PACS, particularly the Universal Viewer. Is there something going on with GE that I'm missing? New PACS? The old one been recalled?<br />
<br />
Inquiring but retired minds want to know!Dalaihttp://www.blogger.com/profile/17775491711029994911noreply@blogger.com1tag:blogger.com,1999:blog-10485390.post-54371593337313537492019-04-14T22:10:00.005-04:002019-04-15T07:08:25.454-04:00Electronic Vindication<div class="separator" style="clear: both; text-align: center;">
<br /></div>
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhhoAgn_zcVOyh5tR1CJriONOd7inS0N4ezeoD5btGsGSJ3A-eAYX-t-kGBeHwhkV0bWVMZm0k7aPJpv8dW4bRpOS2K6W8uqUfEc-SsP2HG2aq3y923spTylHGNly9JpAInfDWm/s1600/The-Impact-of-User-Interfaces-and-Healthcare.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="189" data-original-width="640" height="188" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhhoAgn_zcVOyh5tR1CJriONOd7inS0N4ezeoD5btGsGSJ3A-eAYX-t-kGBeHwhkV0bWVMZm0k7aPJpv8dW4bRpOS2K6W8uqUfEc-SsP2HG2aq3y923spTylHGNly9JpAInfDWm/s640/The-Impact-of-User-Interfaces-and-Healthcare.jpg" width="640" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Dilbert by Scott Adams, courtesy www.dilbert.com</td></tr>
</tbody></table>
<br />
My very first blog post as Doctor Dalai went online on 1/29/2005, beginning with a rant about ScImage lifted from one of my early AuntMinnie.com entries. In the subsequent fourteen years, my writing has become slightly more sophisticated (emphasize <i>slightly</i>), but my basic premise has not wavered: PACS interfaces by and large are not as user-friendly as they could be, in other words, they <i>SUCK</i>. Forgive the epithet, but that is a very accurate statement, and most would agree.<br />
<br />
Most, but not the vendors. In browsing through my years of navel-gazing, I came across several entries wherein the makers of some of these gawd-awful products pushed back. A <a href="https://doctordalai.blogspot.com/2005/05/itl-strikes-back.html">2005 message</a> from a long-defunct company called ITL stood out:<br />
<blockquote class="tr_bq">
We appreciated the time, albeit brief, that Dr. Dalai afforded us, and respect his radiology expertise. While we are disappointed and disagree with his conclusions, it underscores the traditional distinction between image management products and information system solutions. Given his experience with, and knowledge of, particular image management/storage systems this is not surprising. While we don’t question the sincerity of his intentions, it does not provide license for him to make incorrect pronouncements as fact when commenting on RIS/PACS in general, and ITL in particular.</blockquote>
One could argue that PACS is in its own way a boutique product; after all, according to the <a href="https://www.jacr.org/article/S1546-1440(18)30487-3/pdf">JACR</a>, there are something like 32,000 radiologists in the United States, barely a rounding-error on the 1,030,000 number of physicians here. Thus, my fourteen years of whining and moaning about PACS has had a <i>little</i> traction among radiologists and <i>some</i> of the vendors, but not much beyond that. PACS just doesn't rise to the threshold of attention of the wider audience.<br />
<br />
Enter the Electronic Health (or Medical) Record, the EHR (or EMR). Consider this a superset of medical information, including not only the patient's imaging studies, but literally everything else: physician notes, lab results...anything and everything medical. Done correctly, the idea is grand, and I've supported it in the past. Quite vocally, in fact. I was even very much in favor of a <i>National</i> electronic health record, believe it or not. Think of it...your personal records are stored in the cloud, accessible from anywhere. What an incredible contribution to patient care, if done right. And therein lies the rub.<br />
<br />
Remember the little 2005 rant from ITL quoted above? The <a href="https://doctordalai.blogspot.com/2005/05/itl-strikes-back.html">response</a> from the owner of the little imaging center that bought the damn thing was quite telling:<br />
<blockquote class="tr_bq">
I've shared your thoughts with the ITL group that we met with on May 4, 2005. The enclosed attachment is their response to your concerns. Based on their response as well as the points I've listed below, I feel that I must go forward with the purchase of this product:<br />
* I've signed a contract<br />
* (Imaging Center) has the opportunity to save a significant amount of money vs. other PACS systems.<br />
* The product is on a single platform which has benefits that none of the others have.<br />
* Several of the Radiologists in (your) group that I've asked about time saved, said 20% to 40% (over reading from film). If you weigh that against 4 or 5 calls a day until they get used to it, your group comes out way ahead.</blockquote>
This scenario represents a microcosm of the big, bad EMR world out there. Those who don't understand what we do, and don't <i>care</i>, have inflicted much larger, more dysfunctional, and literally deadly software upon the entire medical field. And guess who suffers?<br />
<br />
Let me give you the punchline in case you have something more important to do than read my musings (and I should <i>hope</i> you do!)...As with the majority of PACS systems that I have bemoaned over the past 14 years of blogging, the EMRs are generally not purchased by the end-users, and thus they are written for the CTO and IT department, and for other administrative types. <i>They demonstrate limited, if any, real understanding of the physicians that use them for the life-and-death business of patient care. </i>I've been accused of being a whiny, arrogant doctor for spouting that opinion, but please do show me where I'm wrong. You can't. But it makes perfect economic sense. Why bother writing software to make nasty doctors happy <i>when they don't buy or even maintain it</i>? All they do is <i>use</i> it.<br />
<br />
The dysfunctional EMR's have been (rightly) blamed for everything from physician-burnout to diminished patient care, to actual deaths of patients. I've <a href="https://doctordalai.blogspot.com/2016/03/cinders-ehrs-and-other-disappointments.html">written</a> about them a number of times (the link is to my 2016 post), and we are seeing article after article in the medical and general literature exposing the EMRs for the disappointments they really are.<br />
<br />
You've probably heard of Dr. Atul Gawande, surgeon, author, Renaissance Man, and all-around brilliant guy. He recently wrote a nice piece on this topic in the <a href="https://www.newyorker.com/magazine/2018/11/12/why-doctors-hate-their-computers">New Yorker</a>, "Why Physicians Hate Their Computers," and he pulled no punches:<br />
<blockquote class="tr_bq">
But three years later I’ve come to feel that a system that promised to increase my mastery over my work has, instead, increased my work’s mastery over me. I’m not the only one. A 2016 study found that physicians spent about two hours doing computer work for every hour spent face to face with a patient—whatever the brand of medical software. In the examination room, physicians devoted half of their patient time facing the screen to do electronic tasks. And these tasks were spilling over after hours. The University of Wisconsin found that the average workday for its family physicians had grown to eleven and a half hours. The result has been epidemic levels of burnout among clinicians. Forty per cent screen positive for depression, and seven per cent report suicidal thinking—almost double the rate of the general working population.
<br />
<br />
Something’s gone terribly wrong. Doctors are among the most technology-avid people in society; computerization has simplified tasks in many industries. Yet somehow we’ve reached a point where people in the medical profession actively, viscerally, volubly hate their computers. </blockquote>
Dr. Gawande picked up as well on the fact that doctors were being pushed aside in the decision process:<br />
<blockquote class="tr_bq">
Many of the angriest complaints, however, were due to problems rooted in what Sumit Rana, a senior vice-president at Epic, called “the Revenge of the Ancillaries.” In building a given function—say, an order form for a brain MRI—the design choices were more political than technical: administrative staff and doctors had different views about what should be included. The doctors were used to having all the votes. But Epic had arranged meetings to try to adjudicate these differences. Now the staff had a say (and sometimes the doctors didn’t even show), and they added questions that made their jobs easier but other jobs more time-consuming. Questions that doctors had routinely skipped now stopped them short, with “field required” alerts. A simple request might now involve filling out a detailed form that took away precious minutes of time with patients.</blockquote>
He's nicer about the description than I was, but you get the idea. As I quoted in my own linked article, an insider from the BIG EMR vendor acknowledges that we docs were pretty much cut out of the loop. Dr. Gawande seems to have been luckier than most of us, though that is relative:<br />
<blockquote class="tr_bq">
People wonder, "why aren't EHRs designed with providers in mind?" I've worked at Epic and can tell you why not:<br />
<ul>
<li>Physicians were on staff, but hard to reach. They were technophiles and barely practicing as others mentioned. </li>
</ul>
<ul>
<li>It really is a billing platform with some patient stuff tacked on. </li>
</ul>
<ul>
<li>Everything useful you see is probably a workaround and one level away from not working at all. </li>
</ul>
<ul>
<li>Quality Assurance (manual testers) are supposed to be a surrogate for users, as there is no beta testing. They are intentionally hired without CS background and maintained as laymen with a very lite, monkey-see-monkey-do training. However if they are not lickety-split quick to master the software, they are fired. Quality Assurance ends up being more like Self-Reassurance. </li>
</ul>
<ul>
<li>There is absolutely no testing of interoperability. There is however plenty of testing for the several convoluted ways of sharing data between Epic servers. </li>
</ul>
</blockquote>
Should you doubt the potential for harm from these things, let me refer you to <a href="https://www.huffpost.com/entry/electronic-health-records-tech-problem-lawsuits_b_5c93cb7ee4b07eef7410ea79">"<i>Death By 1,000 Clicks: Where Electronic Health Records Went Wrong,</i>"</a> by Fred Schulte of Kaiser Health News and Erika Fry from Fortune Magazine:<br />
<blockquote>
More gravely still, a months-long joint investigation by KHN and Fortune has found that instead of streamlining medicine, the government’s EHR initiative has created a host of largely unacknowledged patient safety risks. Our investigation found that alarming reports of patient deaths, serious injuries and near misses — thousands of them — tied to software glitches, user errors or other flaws have piled up, largely unseen, in various government-funded and private repositories.</blockquote>
In the case of a particularly bad product from a company called eCW.<br />
<blockquote class="tr_bq">
The eCW spaghetti code was so buggy that when one glitch got fixed, another would develop, the government found. The user interface offered a few ways to order a lab test or diagnostic image, for example, but not all of them seemed to function. The software would detect and warn users of dangerous drug interactions, but unbeknownst to physicians, the alerts stopped if the drug order was customized. “It would be like if I was driving with the radio on and the windshield wipers going and when I hit the turn signal, the brakes suddenly didn’t work,” said Foster.</blockquote>
And by the way, you aren't even supposed to know about these potentially fatal glitches:<br />
<blockquote class="tr_bq">
Compounding the problem are entrenched secrecy policies that continue to keep software failures out of public view. EHR vendors often impose contractual “gag clauses” that discourage buyers from speaking out about safety issues and disastrous software installations — though some customers have taken to the courts to air their grievances. Plaintiffs, moreover, say hospitals often fight to withhold records from injured patients or their families. Indeed, two doctors who spoke candidly about the problems they faced with EHRs later asked that their names not be used, adding that they were forbidden by their health care organizations to talk. Says Assistant U.S. Attorney Foster, the EHR vendors “are protected by a shield of silence.”
<br />
<br />
...KHN and Fortune examined more than two dozen medical negligence cases that have alleged that EHRs either contributed to injuries, had been improperly altered, or were withheld from patients to conceal substandard care. In such cases, the suits typically settle prior to trial with strict confidentiality pledges, so it’s often not possible to determine the merits of the allegations. EHR vendors also frequently have contract stipulations, known as “hold harmless clauses,” that protect them from liability if hospitals are later sued for medical errors — even if they relate to an issue with the technology.</blockquote>
So how does a poorly functioning piece of crap become entrusted with critical patient information? As usual, the government ruined what should have been a great and wonderful thing:<br />
<blockquote class="tr_bq">
...10 years after President Barack Obama signed a law to accelerate the digitization of medical records — with the federal government, so far, sinking $36 billion into the effort — America has little to show for its investment. KHN and Fortune spoke with more than 100 physicians, patients, IT experts and administrators, health policy leaders, attorneys, top government officials and representatives at more than a half-dozen EHR vendors, including the CEOs of two of the companies. The interviews reveal a tragic missed opportunity: Rather than an electronic ecosystem of information, the nation’s thousands of EHRs largely remain a sprawling, disconnected patchwork. Moreover, the effort has handcuffed health providers to technology they mostly can’t stand and has enriched and empowered the $13-billion-a-year industry that sells it.<br />
<br />
David Blumenthal, who, as Obama’s national coordinator for health information technology, was one of the architects of the EHR initiative, acknowledged to KHN and Fortune that electronic health records “have not fulfilled their potential. I think few would argue they have.”<br />
<br />
...Seema Verma, the current chief of the Centers for Medicare & Medicaid Services (CMS), which oversees the EHR effort today, shudders at the billions of dollars spent building software that doesn’t share data — an electronic bridge to nowhere. “Providers developed their own systems that may or may not even have worked well for them,” she told KHN and Fortune in an interview last month, “but we didn’t think about how all these systems connect with one another. That was the real missing piece.”</blockquote>
<div>
This government-participation movie has played out in another country I've heard about (which shall remain nameless), where any public entity, like a medical school, is required to buy equipment and service from one particular company...which has absolutely no idea what it is doing, and is responsible for a good number of idle diagnostic machines. While the US government doesn't go this far, there is certainly enough money flowing to help us understand how we were delivered Pintos for the price of Mercedes.<br />
<br />
And there was perhaps a more sinister thought behind the rapid governmental push for EMRs. Betsy McCaughey, former Lieutenant Governor of New York, <a href="https://nypost.com/2019/03/28/e-record-rules-are-burning-out-docs-and-killing-patients/?utm_campaign=iosapp&utm_source=facebook_app&fbclid=IwAR2I2SrFQnGDi-mzFGDTZE7vzuhjgIh6aPb_6VKFAZ7OKZKI1kl1RmfsHU0">writes</a>:<br />
<blockquote class="tr_bq">
Obama’s high-tech guru, Dr. David Blumenthal, wanted top-down control of the treatment decisions doctors make. Doctors have to follow computer prompts or be punished financially with lower Medicare payments. Blumenthal predicted doctors would resist the loss of autonomy, but he also promised it would result in better care and savings from fewer unnecessary tests and treatments. He was right about doctors resisting but wrong about everything else.<br />
<br />
Stanford University researchers examining hospital records from six states, including New York and California, found that hospitals complying with the electronic records mandate don’t have better patient outcomes or survival rates.</blockquote>
<br />
As with PACS, the designers of the interfaces have absolutely no clue about physician workflow. Let's see...what would we like to do with and EMR? How about order a Tylenol for Mrs. Jones in Room 973? Good luck. Schulte and Fry continue:<br />
<blockquote class="tr_bq">
In a study published last year in the journal Health Affairs, Ratwani and colleagues studied medication errors at three pediatric hospitals from 2012 to 2017. They discovered that 3,243 of them were owing in part to EHR “usability issues.” Roughly 1 in 5 of these could have resulted in patient harm, the researchers found. “Poor interface design and poor implementations can lead to errors and sometimes death, and that is just unbelievably bad as well as completely fixable,” he said. “We should not have patients harmed this way.”<br />
<br />
Using eye-tracking technology, Ratwani has demonstrated on video just how easy it is to make mistakes when performing basic tasks on the nation’s two leading EHR systems. When emergency room doctors went to order Tylenol, for example, they saw a drop-down menu listing 86 options, many of which were irrelevant for the specified patient. They had to read the list carefully, so as not to click the wrong dosage or form — though many do that too: In roughly 1 out of 1,000 orders, physicians accidentally select the suppository (designated “PR”) rather than the tablet dose (“OR”), according to one estimate. That’s not an error that will harm a patient — though other medication mix-ups can and do.</blockquote>
</div>
<div>
Oops. I personally think getting a suppository is traumatic and harmful, but that's just me. Atul Gawande asked a colleague about ordering things in her EMR:<br />
<blockquote class="tr_bq">
“Ordering a mammogram used to be one click,” she said. “Now I spend three extra clicks to put in a diagnosis. When I do a Pap smear, I have eleven clicks. It’s ‘Oh, who did it?’ Why not, by default, think that I did it?” She was almost shouting now. “I’m the one putting the order in. Why is it asking me what date, if the patient is in the office today? When do you think this actually happened? It is incredible!” The Revenge of the Ancillaries, I thought.</blockquote>
Once again...those who built these monuments to bad technology did not ask the people who USE their little darlings how they should work...<i>because the end-users do not buy these incredibly expensive systems. </i>And our beloved United States Government was a BIG part of the problem:<br />
<blockquote>
The effort to digitize America’s health records got its biggest push in a very low moment: the financial crisis of 2008. In early December of that year, Obama, barely four weeks after his election, pitched an ambitious economic recovery plan. “We will make sure that every doctor’s office and hospital in this country is using cutting-edge technology and electronic medical records so that we can cut red tape, prevent medical mistakes and help save billions of dollars each year,” he said in a radio address...<br />
<br />
In the depths of recession, the EHR conceit looked like a shovel-ready project that only the paper lobby could hate. In February 2009, legislators passed the HITECH Act, which carved out a hefty chunk of the massive stimulus package for health information technology. The goal was not just to get hospitals and doctors to buy EHRs, but rather to get them using them in a way that would drive better care. So lawmakers devised a carrot-and-stick approach: Physicians would qualify for federal subsidies (a sum of up to nearly $64,000 over a period of years) only if they were “meaningful users” of a government-certified system. Vendors, for their part, had to develop systems that met the government’s requirements.<br />
<br />
They didn’t have much time, though. The need to stimulate the economy, which meant getting providers to adopt EHRs quickly, “presented a tremendous conundrum,” said Farzad Mostashari, who joined the ONC as deputy director in 2009 and became its leader in 2011: The ideal — creating a useful, interoperable, nationwide records system — was “utterly infeasible to get to in a short time frame.”
<br />
<br />
That didn’t stop the federal planners from pursuing their grand ambitions. Everyone had big ideas for the EHRs. The FDA wanted the systems to track unique device identifiers for medical implants, the Centers for Disease Control and Prevention wanted them to support disease surveillance, CMS wanted them to include quality metrics and so on. “We had all the right ideas that were discussed and hashed out by the committee,” said Mostashari, “but they were all of the right ideas.”</blockquote>
<i><br /></i>One major promise of the EMR is interconnectivity. I should be able to set foot in any hospital in the world, or at least in the United States, and have my data available instantly. But there was one small impediment to that ideal:<br />
<br />
<blockquote class="tr_bq">
The notion that one EHR should talk to another was a key part of the original vision for the HITECH Act, with the government calling for systems to be eventually interoperable.<br />
<br />
What the framers of that vision didn’t count on were the business incentives working against it. A free exchange of information means that patients can be treated anywhere. And though they may not admit it, many health providers are loath to lose their patients to a competing doctor’s office or hospital. There’s a term for that lost revenue: “leakage.” And keeping a tight hold on patients’ medical records is one way to prevent it.</blockquote>
<br />
As usual, those who think like the government, at least the government in place at the time, never, ever, EVER consider the unexpected consequences that human nature will inevitably provide. In this case, the possessiveness (dare I say <i>greed</i>?) of hospitals (and, yes, doctors) scuttled what should have been a given. And people have been harmed, even died, because one system would not talk to another. I guess the patient's home systems considers it a draw if the poor fellow dies or is treated by a competitor.<br />
<br />
What is almost as sad as the loss of a patient is the loss of a soul. More and more physicians are burning out, losing their calling, losing their souls, precisely because of this disgusting situation. How did THAT happen? Gawande again:<br />
<blockquote class="tr_bq">
Adaptation requires two things: <u>mutation</u> and <u>selection</u>. <u>Mutation</u> produces variety and deviation; <u>selection</u> kills off the least functional mutations. Our old, craft-based, pre-computer system of professional practice—in medicine and in other fields—was all mutation and no selection. There was plenty of room for individuals to do things differently from the norm; everyone could be an innovator. But there was no real mechanism for weeding out bad ideas or practices. <i>Computerization, by contrast, is all selection and no mutation.</i> Leaders install a monolith, and the smallest changes require a committee decision, plus weeks of testing and debugging to make sure that fixing the daylight-saving-time problem, say, doesn’t wreck some other, distant part of the system...<br />
<br />
But those processes cannot handle more than a few change projects at a time. Artisanship has been throttled, and so has our professional capacity to identify and solve problems through ground-level experimentation. Why can’t our work systems be like our smartphones—flexible, easy, customizable? The answer is that the two systems have different purposes. Consumer technology is all about letting me be me. Technology for complex enterprises is about helping groups do what the members cannot easily do by themselves—work in coördination. Our individual activities have to mesh with everyone else’s. What we want and don’t have, however, is a system that accommodates both mutation and selection.</blockquote>
But selection is winning over mutation. Schulte and Fry:<br />
<blockquote class="tr_bq">
The numbing repetition, the box-ticking and the endless searching on pulldown menus are all part of what Ratwani called the “cognitive burden” that’s wearing out today’s physicians and driving increasing numbers into early retirement.<br />
<br />
In recent years, “physician burnout” has skyrocketed to the top of the agenda in medicine. A 2018 Merritt Hawkins survey found a staggering 78 percent of doctors suffered symptoms of burnout, and in January the Harvard School of Public Health and other institutions deemed it a “public health crisis.”<br />
<br />
One of the co-authors of the Harvard study, Ashish Jha, pinned much of the blame on “the growth in poorly designed digital health records ... that [have] required that physicians spend more and more time on tasks that don’t directly benefit patients...”
<br />
<br />
“Everything is so cumbersome,” said Dr. Karla Dick, a family medicine physician in Arlington, Texas. “It’s slow compared to a paper chart. You’re having to click and zoom in and zoom out to look for stuff.” With all the zooming in and out, she explained, it’s easy to end up in the wrong record. “I can’t tell you how many times I’ve had to cancel an order because I was in the wrong chart.”</blockquote>
Neither an EMR or a PACS is a product of rocket science. They are basically large databases, with alphanumeric entries of notes and labs to be found in the "chart" side, and images to be found on the 'ology side, X-Rays, CT scans, even images of skin lesions (Dermat<i>ology</i>) and histopath slides (Path<i>ology</i>). This shouldn't be hard. But it is because of the huge amounts of money involved, as well as the buffoonish, bulldozing intervention of a (supposedly) well-intentioned government.<br />
<br />
This is a macrocosm of the PACS world, but even more intimately involved in the patient's care. And with even greater potential to harm the patient. Or kill him. Schulte and Fry quote Dr. Ratwani for the last word of this sad missive:<br />
<blockquote class="tr_bq">
In a study published last year in the journal Health Affairs, Ratwani and colleagues studied medication errors at three pediatric hospitals from 2012 to 2017. They discovered that 3,243 of them were owing in part to EHR “usability issues.” Roughly 1 in 5 of these could have resulted in patient harm, the researchers found. “Poor interface design and poor implementations can lead to errors and sometimes death, and that is just unbelievably bad as well as completely fixable,” he said. “We should not have patients harmed this way.”</blockquote>
</div>
Let me repeat that for emphasis:<br />
<br />
<blockquote class="tr_bq">
<span style="font-size: x-large;">“Poor interface design and poor implementations can lead to errors and sometimes death, and that is just unbelievably bad as well as completely fixable. We should not have patients harmed this way.”</span></blockquote>
<br />
Which is what I've been saying about PACS for a very long time.Dalaihttp://www.blogger.com/profile/17775491711029994911noreply@blogger.com0tag:blogger.com,1999:blog-10485390.post-2633570816798815102019-04-10T10:22:00.002-04:002019-04-10T21:01:31.467-04:00The "Heart" Of Darkness?Black holes are the stuff of science, science fiction, and even fantasy, but they <i>are</i> real. Until now, however, no one has ever seen one. Until now:<br />
<div>
<br /></div>
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgJhNokz_Y22NZIOLi1n_r9ldPQdRWJH7H2DBnnjOETOyOC9nyxmwC_zCgMNrM52oylwKxd16jSr0soHh8ImBzs2MnNt_gt-IvDDrkix5cTh1HEjZcbdx5n6_fgH0xjgIHw8MbF/s1600/black+hole.png" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="466" data-original-width="800" height="372" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgJhNokz_Y22NZIOLi1n_r9ldPQdRWJH7H2DBnnjOETOyOC9nyxmwC_zCgMNrM52oylwKxd16jSr0soHh8ImBzs2MnNt_gt-IvDDrkix5cTh1HEjZcbdx5n6_fgH0xjgIHw8MbF/s640/black+hole.png" width="640" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Image courtesy PBS.com</td></tr>
</tbody></table>
<div>
<br /></div>
<div>
From <a href="http://pbs.comhttps//www.pbs.org/newshour/science/here-is-the-first-photo-of-a-black-hole?fbclid=IwAR0co-ZKX5264i7GfBIMr-_2KFANFGRerwFCYKy2zo4VxZasQmTHOd-67YQ">PBS.com</a>:</div>
<div>
<br /></div>
<blockquote>
On Wednesday, the Event Horizon Telescope released the first-ever image of a black hole — a historic moment shared by scientists spread across seven simultaneous news conferences around the world.
As the PBS NewsHour reported Tuesday, the Event Horizon Telescope is a two-year-old, international collaboration bent on capturing direct pictures of black holes:
<br />
<br />
Two years ago, an international collective of scientists joined forces to take pictures of two black holes located at the centers of galaxies.
<br />
<br />
Scientists at eight radio telescopes observatories — stretching from Hawaii to Greenland to the French Alp to Antarctica — captured images of one black hole in our Milky Way — known as Sagittarius A* — and one in a nearby galaxy called M87, over the course of a week in April 2017. (The PBS NewsHour visited one in Chile when the project was still under discussion).
<br />
<br />
By linking together, the scientists created, in essence, a planet-sized telescope built to scan massive parts of the skies.
<br />
<br />
The concept of black holes has captivated scientists for two centuries. Despite decades of indirect evidence supporting their existence, black holes have never been captured by camera — until now. Scientists hope to use the image to probe the origins of our universe.
</blockquote>
<div>
<br /></div>
<div>
My friend Stacey saw this before I did and immediately made the comparison to a myocardial perfusion scan, in this case demonstrating an anterior wall defect:<br />
<br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi1yK7qgb-Re9LrzRBs70A47d_AEcugSp7zpsMGjVDmY0uZ_3FIhK9S5gXfQjleNx2vikoSbxqLj5ZU5Q8el9yqaBi3xsQz4oEcw4Njcjkz2KDH6522Ovp_AM9XRQAAObNG4-g2/s1600/jacc.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="751" data-original-width="1280" height="233" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi1yK7qgb-Re9LrzRBs70A47d_AEcugSp7zpsMGjVDmY0uZ_3FIhK9S5gXfQjleNx2vikoSbxqLj5ZU5Q8el9yqaBi3xsQz4oEcw4Njcjkz2KDH6522Ovp_AM9XRQAAObNG4-g2/s400/jacc.jpg" width="400" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Image courtesy JACC.com</td></tr>
</tbody></table>
Truly, the "Heart of Darkness"! Ah, if we could only look into the soul with as much insight...<br />
<br />
The images of Pluto had already suggested to me that G-d plays games with us:<br />
<br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiQG-9IqK8rD341GsBcTMoPz07yz1WerHA9T3hCy-KPcafZdCFrl57Z3MwGfC9rBGAOnuu0d-kC_na09b94wSing9yCyC5M-bBIzuvKwv8lzQXlWjAi-fx-gGlRPWUYQU2ntk7r/s1600/plutoonpluto.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="508" data-original-width="1024" height="197" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiQG-9IqK8rD341GsBcTMoPz07yz1WerHA9T3hCy-KPcafZdCFrl57Z3MwGfC9rBGAOnuu0d-kC_na09b94wSing9yCyC5M-bBIzuvKwv8lzQXlWjAi-fx-gGlRPWUYQU2ntk7r/s400/plutoonpluto.jpg" width="400" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Image courtesy plutosafari.com</td></tr>
</tbody></table>
Now I know it's true!</div>
Dalaihttp://www.blogger.com/profile/17775491711029994911noreply@blogger.com0tag:blogger.com,1999:blog-10485390.post-85135855585887950902019-04-04T16:09:00.001-04:002019-04-05T06:57:22.678-04:00Sudbury Is Still Waiting...<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi_jFENabgZM9JtDRw_TcpbECpar9MIHuj3aO7-SyyS1IYTHO1Md458yUSTq3WBPFHo_i5Q-K2lfT3Ax7fKo_VfVDJwh2O7eUcuzxd4ozU1sQleURvYMyO3vl-9fNShOVUXg5H4/s1600/010419_mri2-billcrumplin-donnawilliams.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="600" data-original-width="900" height="266" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi_jFENabgZM9JtDRw_TcpbECpar9MIHuj3aO7-SyyS1IYTHO1Md458yUSTq3WBPFHo_i5Q-K2lfT3Ax7fKo_VfVDJwh2O7eUcuzxd4ozU1sQleURvYMyO3vl-9fNShOVUXg5H4/s400/010419_mri2-billcrumplin-donnawilliams.jpg" width="400" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Bill Crumplin, with photo of his late wife Donna Williams, image courtesy Sudbury.com</td></tr>
</tbody></table>
You might recall my <a href="https://doctordalai.blogspot.com/2016/02/brother-can-you-spare-dime-010-cad-for.html">post</a> of a few years ago about Sudbury, Ontario, Canada, a medium-sized town that turned to its citizens to fund a PET/CT facility when the much-touted Health Service would not provide it. The wait-time was not just an inconvenience; the health of Sudbury citizens was adversely affected by the lack of local scanning capability.<span id="goog_766248283"></span><br />
<br />
The wait goes on, it seems.<br />
<br />
My friend Stacey discovered <i>another</i> such tragedy related to imaging, or rather, lack thereof. As reported on <a href="https://www.sudbury.com/local-news/her-dying-wish-donna-williams-died-too-soon-but-the-push-she-started-for-a-second-mri-scanner-continues-1353214">Sudbury.com</a>:<br />
<br />
<blockquote>
Donna Williams’ dying wish was to raise money toward the purchase of a piece of medical equipment that would have helped doctors diagnose her illness sooner and perhaps changed the course of her treatment. And her life.
<br />
<br />
Williams, 54, died April 6, 2016, of cardiac amyloidosis, a disorder caused by deposits of an abnormal protein in heart tissue, making it difficult for the heart to function properly.
<br />
<br />
The Sudbury woman was scheduled to have a cardiac MRI in Ottawa, but wasn’t healthy enough to travel there and sadly died two weeks after being diagnosed.
<br />
<br />
Bill Crumplin said he and Williams, an exceptionally bright woman, did not make it to their fourth wedding anniversary before she succumbed “brutally fast” to the rare disease. Had she been able to have a cardiac magnetic resonance imaging (the full name of an MRI) scan in January 2016 rather than March, the outcome might have been different.
<br />
<br />
{snip}<br />
<br />
SN is operating its one MRI machine 24 hours a day, 365 days a year, completing about 13,000 scans a year. Still patients must wait an average 52 days for a test that should be performed within the provincial target of 28 days.
<br />
<br />
{snip}<br />
<br />
Health Sciences North Foundation executive director Mary Lou Hussak is leading the drive to raise more than $6 million for the scanners. The foundation is focusing all its efforts right now on raising the $3.5 million for the purchase and installation of a second MRI, then $2.6 million to replace the first.
<br />
<br />
So far, $1.1 million has been raised, without campaigning, thanks to a $500,000 donation from Carmen and Sandy Fielding and another so far anonymous $500,000 donation.
<br />
<br />
Hussak has no doubt residents of Sudbury and the Northeast will give generously to the MRI fund. While some have made huge donations, all amounts, large or small, will be gratefully accepted.
<br />
<br />
People can make individual or company donations, or hold small events such as birthday or tea parties or dinners in their home where friends can donate to the cause. Hussak encourages people thinking of holding such events to contact the foundation because it has resources that could make that easier.
<br />
<br />
{snip}<br />
<br />
Meanwhile, construction continues at HSN’s Ramsey Lake Health Centre on the suite to accommodate a combined positron emission tomography/computed tomography scanner. There was a short delay in the early days, said Hartman, but efforts are being made to make up for lost time. The hospital estimates the suite will be finished in the spring and do the first PET scan this summer.
</blockquote>
<div style="text-align: left;">
Oh, myyyyyyy....</div>
<div style="text-align: left;">
<br /></div>
<div style="text-align: center;">
<iframe allowfullscreen="" class="giphy-embed" frameborder="0" height="270" src="https://giphy.com/embed/asHT7eh4AwG9G" width="480"></iframe><br /></div>
<div style="text-align: center;">
<br /></div>
<div style="text-align: center;">
<br /></div>
<div style="text-align: left;">
So...it has taken three years to get the PET/CT scanner we heard about it 2016? Lovely. And the citizens of Sudbury have to take up collections and hold tea-parties to fund another MRI so critical patients (I have to say it) don't DIE waiting for their scans? The article neglects to mention the possibility of bake sales and selling Sally Foster gift-wrap, both big revenue-producers when my kids were in school. </div>
<div style="text-align: left;">
<br /></div>
<div style="text-align: left;">
Houston, I mean Sudbury, we have a problem. </div>
<div style="text-align: left;">
<br /></div>
<div style="text-align: left;">
The Canadian system is the quintessential bureaucracy, and as such keeps meticulous records. In this case, wait-times are accessible via a Provincial website, <a href="http://www.hqontario.cahttps//www.hqontario.ca/System-Performance/Wait-Times-for-Diagnostic-Imaging?utm_source=Ontario.ca&utm_medium=Referral&utm_campaign=WT%20Referral">http://www.hqontario.ca</a>. Read 'em and weep:</div>
<div style="text-align: left;">
<br /></div>
<div class="separator" style="clear: both; text-align: center;">
</div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgN4kYQumo9K4w_YZk8P2HzfjO5QVcC8yHkHnJEreAUVut8WHLEJVLN1RRdukxWL9pPXENmTi2UHB-NJiI4VABfPYF1WyVKMU8V8EgaMwWKz3AQm7pngPj8meI_gB_MuxD1WM1v/s1600/Screen+Shot+2019-04-04+at+4.00.35+PM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1600" data-original-width="1361" height="640" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgN4kYQumo9K4w_YZk8P2HzfjO5QVcC8yHkHnJEreAUVut8WHLEJVLN1RRdukxWL9pPXENmTi2UHB-NJiI4VABfPYF1WyVKMU8V8EgaMwWKz3AQm7pngPj8meI_gB_MuxD1WM1v/s640/Screen+Shot+2019-04-04+at+4.00.35+PM.png" width="544" /></a></div>
<div style="text-align: left;">
<br /></div>
<div style="text-align: left;">
I really don't need to add much of an editorial comment here, do I? But that never stops me, so I'll simply repeat more or less what I said about Sudbury's PET/CT in 2016, and it remains accurate in my humble opinion:</div>
<div style="text-align: left;">
<br /></div>
The healthcare here in the United States is good. Really, really good. People who can afford to do so come HERE to be diagnosed and treated. Those who can afford to come HERE do NOT go to Canada. Or Germany. Or Switzerland. Or Sweden. Or India. Or Anywhere Else. Even Mick Jagger, a British Citizen, is having a heart-valve replacement tomorrow in <i>New York City</i>, and not London. I'm not saying I contribute much, if anything, to it, but the best medicine in the world is practiced in the United States. I don't think our system is perfect, and I have called for massive reforms, dumping Obamacare, Medicare, Medicaid, and revamping the whole thing including a huge revision of the laws governing the Third-Party Payers, our beloved insurance companies. Ours is a dysfunctional system and it has to be revised. But even with its blemishes, it produces some of the best medicine in the world.<br />
<br style="background-color: black; color: #b9b9b9; font-family: "Trebuchet MS", Trebuchet, sans-serif; font-size: 16px;" />
And yet, in our inexorable march toward Socialism, the latest incarnation of which is called "Medicare for All", led by demagogues who would have us trade everything that makes America America for "free stuff", American health care stands to be crippled in the process of making it "free". And by the way, nothing is "free". Someone has to pay for the "free stuff".<br />
<br style="background-color: black; color: #b9b9b9; font-family: "Trebuchet MS", Trebuchet, sans-serif; font-size: 16px;" />
We need to look at the case of imaging in Sudbury and understand the implications. There isn't enough money in Ontario to provide enough "free" scanners for Sudbury, and in fact, funds for this life-saving technology are limited province-wide. Thus, the fine people of Sudbury will have to fund the purchase themselves. That they are <i>willing</i> to do so to help their fellow citizens is the heart<i>warming </i>part of this story. The heart<i>breaking</i> aspect is that they <i>have</i> to do so. I see this as a huge crack in the perfect facade of Canada's single payer system. It FAILED the people of Sudbury. And it fails the people of Ontario, and indeed all of Canada by limiting resources and thus rationing their care.<br />
<br />
The profit motive has brought an overabundance of expensive CT, MRI, and PET/CT scanners to the United States, with the inherent likelihood of over utilization. My town of less than 200,000 may well have as many scanners as all of Ontario; certainly our small, relatively poor state has a significant multiple of the technology. Contrast this to the neighbourly situation in Ontario which requires the citizens themselves to raise money for life-saving technology that the government, even using the generously given tax-dollars (CAD) cannot provide.<br />
<div>
<br /></div>
<div>
This is not the answer to fixing healthcare in the United States. Sorry.<br />
<div style="text-align: left;">
<br /></div>
</div>
Dalaihttp://www.blogger.com/profile/17775491711029994911noreply@blogger.com0tag:blogger.com,1999:blog-10485390.post-92096296148044857892019-04-03T16:49:00.000-04:002019-04-03T17:23:38.075-04:00How IBM Watson Overpromised and Underdelivered on AI Health Care<i>My friend Phil Shaffer, a fellow retired Nuclear Radiologist, is an avid poster on Aunt Minnie. His AM post today about AI in general and Watson in particular is worthy of a wider audience, and here you are. It is based on an Engineering article in the IEEE Spectrum: <a href="https://spectrum.ieee.org/biomedical/diagnostics/how-ibm-watson-overpromised-and-underdelivered-on-ai-health-care">How IBM Watson Overpromised and Underdelivered on AI Health Care </a>. This is a cautionary tale for all who have anything to do with AI...If IBM stumbled in this venue, if IBM could fall victim to hype and hubris...</i><br />
<div class="msg" id="msg573968" style="box-sizing: border-box;">
<span style="font-family: "arial" , "helvetica" , sans-serif;"><span style="background-color: white;"> </span></span><br />
Well, we all knew that. Big hype, zero output. <br />
<br />
I wouldn't bother to post this non-news, if it were not for the other questions it brings up.<br />
<blockquote class="tr_bq">
<br />
IBM’s bold attempt to revolutionize health care began in 2011. The day after Watson thoroughly defeated two human champions in the game of Jeopardy!, IBM <a href="https://www-03.ibm.com/press/us/en/pressrelease/33726.wss">announced a new career path</a> for its AI quiz-show winner: It would become an AI doctor. IBM would take the breakthrough technology it showed off on television—mainly, the ability to understand natural language—and apply it to medicine. Watson’s first commercial offerings for health care would be available in 18 to 24 months, the company promised.<br />
<br />
In fact, the projects that IBM announced that first day did not yield commercial products. In the eight years since, IBM has trumpeted many more high-profile efforts to develop AI-powered medical technology—many of which have fizzled, and a few of which have failed spectacularly. The company spent billions on acquisitions to bolster its internal efforts, but insiders say the acquired companies <a href="https://spectrum.ieee.org/the-human-os/robotics/artificial-intelligence/layoffs-at-watson-health-reveal-ibms-problem-with-ai">haven’t yet contributed much</a>. And the products that have emerged from <a href="https://www.ibm.com/watson/health/">IBM’s Watson Health</a> division are nothing like the brilliant AI doctor that was once envisioned: They’re more like AI assistants that can perform certain routine tasks.<br />
<br />
In part, he says, IBM is suffering from its ambition: It was the first company to make a major push to bring AI to the clinic. But it also earned ill will and skepticism by boasting of Watson’s abilities. “They came in with marketing first, product second, and got everybody excited,” he says. “Then the rubber hit the road. This is an incredibly hard set of problems, and IBM, by being first out, has demonstrated that for everyone else.”<br />
<br />
The diagnostic tool, for example, wasn’t brought to market because the business case wasn’t there, says <a href="https://researcher.watson.ibm.com/researcher/view.php?person=us-ajayr">Ajay Royyuru</a>, IBM’s vice president of health care and life sciences research. “Diagnosis is not the place to go,” he says. “That’s something the experts do pretty well. It’s a hard task, and no matter how well you do it with AI, it’s not going to displace the expert practitioner.” (Not everyone agrees with Royyuru: A <a href="https://www.nap.edu/catalog/21794/improving-diagnosis-in-health-care">2015 report on diagnostic error</a>s from the National Academies of Sciences, Engineering, and Medicine stated that improving diagnoses represents a “moral, professional, and public health imperative.”)<br />
<br />
In many attempted applications, Watson’s NLP struggled to make sense of medical text—as have many other AI systems. “We’re doing incredibly better with NLP than we were five years ago, yet we’re still incredibly worse than humans,” says <a href="https://mila.quebec/en/yoshua-bengio/">Yoshua Bengio</a>, a professor of computer science at the University of Montreal and a leading AI researcher. In medical text documents, Bengio says, AI systems can’t understand ambiguity and don’t pick up on subtle clues that a human doctor would notice.<br />
<br />
Both efforts have received strong criticism. <a href="https://www.statnews.com/2018/07/25/ibm-watson-recommended-unsafe-incorrect-treatments/">One excoriating article</a> about Watson for Oncology alleged that it provided useless and sometimes dangerous recommendations (IBM <a href="https://www.ibm.com/blogs/watson-health/ai-healthcare-challenges/">contests these allegations</a>). More broadly, Kris says he has often heard the critique that the product isn’t “real AI.” And the MD Anderson project failed dramatically: A <a href="https://www.utsystem.edu/sites/default/files/documents/UT%20System%20Administration%20Special%20Review%20of%20Procurement%20Procedures%20Related%20to%20UTMDACC%20Oncology%20Expert%20Advisor%20Project/ut-system-administration-special-review-procurement-procedures-related-utmdacc-oncology-expert-advis.pdf">2016 audit by the University of Texas</a> found that the cancer center spent $62 million on the project before canceling it. <b>A deeper look at these two projects reveals a fundamental mismatch between the promise of machine learning and the reality of medical care—between “real AI” and the requirements of a functional product for today’s doctors.</b><br />
<br />
Watson learned fairly quickly how to scan articles about clinical studies and determine the basic outcomes. But it proved impossible to teach Watson to read the articles the way a doctor would. “The information that physicians extract from an article, that they use to change their care, may not be the major point of the study,” Kris says. Watson’s thinking is based on statistics, so all it can do is gather statistics about main outcomes, explains Kris. “But doctors don’t work that way.”</blockquote>
</div>
<div class="msg" id="msg573968" style="box-sizing: border-box;">
<div>
<br />
At MD Anderson, researchers put Watson to work on leukemia patients’ health records—and quickly discovered how tough those records were to work with. Yes, Watson had phenomenal NLP skills. But in these records, data might be missing, written down in an ambiguous way, or out of chronological order. <br />
<br />
In a final blow to the dream of an AI superdoctor, researchers realized that Watson can’t compare a new patient with the universe of cancer patients who have come before to discover hidden patterns <br />
<br />
If an AI system were to base its advice on patterns it discovered in medical records—for example, that a certain type of patient does better on a certain drug—its recommendations wouldn’t be considered evidence based, the gold standard in medicine. Without the strict controls of a scientific study, such a finding would be considered only correlation, not causation. </div>
<div style="background-color: white; font-family: arial, helvetica, sans-serif;">
<br style="box-sizing: border-box;" /></div>
The question this raises in my mind is: Why? <br />
<br />
It seemed so intuitive that this would work. Why doesn't it? <br />
<br />
One thing that happens when you try to apply computers to any problem is that first you must break down the task and understand completely how humans do it. I think that what we are seeing is that there was a very incomplete understanding of how humans process information. Starting with a naive understanding of this, IBM brazenly predicted success. And failed. Miserably. <br />
<div style="background-color: white; font-family: arial, helvetica, sans-serif;">
</div>
Another important point is that much of our scientific effort is reported as statistical differences, derived from controlled experiments. But this is NOT the way that medicine works. There is another level, as <a href="https://lukeoakdenrayner.wordpress.com/2019/01/21/medical-ai-safety-doing-it-wrong/">Luke Oakden-Rayner</a> has pointed out. <br />
<br />
He points out - convincingly - that experiments are NOT clinical performance.<br />
<br />
<blockquote class="tr_bq" style="box-sizing: border-box;">
Medical AI today is assessed with performance testing; controlled laboratory experiments that do not reflect real-world safety.<br />
<br />
Performance is not outcomes! Good performance in laboratory experiments rarely translates into better clinical outcomes for patients, or even better financial outcomes for healthcare systems.<br />
Humans are probably to blame. We act differently in experiments than we do in practice, because our brains treat these situations differently.<br />
<br />
Even fully autonomous systems interact with humans, and are not protected from these problems. We know all of this because of one of the most expensive, unintentional experiments ever undertaken. At a cost of hundreds of millions of dollars per year, the US government paid people to use previous generation AI in radiology. It failed, and possibly resulted in thousands of missed cancer diagnoses compared to best practice, because we had assumed that laboratory testing was enough.</blockquote>
</div>
<div class="msg" id="msg573968" style="box-sizing: border-box;">
<br />
The unintentional experiment he references is Breast CAD. <br />
<br />
He recounts how the initial studies suggested that there would be 20% more cancers found using CAD, however subsequent VERY LARGE studies showed (in one case) a 20% increase in biopsies for an increase in cancers found from 4.15 per 1000 to 4.20 per thousand (p = NS). <br />
<br />
His diagnosis: <br />
<br />
<blockquote class="tr_bq">
People are weird. It turns out that if you run an experiment with doctors being asked to review cases with CAD, they get more vigilant. If you give them CAD and make them use it clinically, they get less vigilant than if you never gave it to them in the first place.<br />
There are a range of things going on here, but the most important is probably the laboratory effect. As several studies have shown [5, 6], when people are doing laboratory studies (i.e., controlled experiments) they behave differently than when they are treating real patients. The <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2607194/#B14">latter study</a> concluded:<br />
<br />
“Retrospective laboratory experiments may not represent either expected performance levels or inter-reader variability during clinical interpretations of the same set of mammograms”<br />
<br />
Which really says it all.</blockquote>
<div style="background-color: white; font-family: arial, helvetica, sans-serif;">
<br style="box-sizing: border-box;" /></div>
He goes on to say that when people use computers they over value what computer input and under value the other evidence:<br />
<div style="background-color: white; font-family: arial, helvetica, sans-serif;">
</div>
<blockquote class="tr_bq">
This effect has been implicated in several recent deaths in partially self-driving cars – it has been shown that even trained safety drivers <a href="https://www.reuters.com/article/us-alphabet-autos-self-driving/google-ditched-autopilot-driving-feature-after-test-user-napped-behind-wheel-idUSKBN1D00MD?il=0">are unable to remain vigilant</a> in autonomous cars that work most of the time.<br />
<br />
This effect has also been directly cited as a possible reason for the failure of mammography CAD. One particularly interesting study showed that using CAD resulted in worse sensitivity (less cancers picked up) when the CAD feedback contained more inaccuracies [8] (<a href="http://openaccess.city.ac.uk/1589/1/AcademicRadiology04.pdf">pdf link</a>). On the surface this didn’t make a lot of sense, since CAD was never meant to be used to exclude cases; it was approved to highlight additional areas of concern, and the radiologists were supposed to use their own judgement for the remainder of the image. Instead, we find that radiologists are reassured by a lack of highlighted regions (or by dismissing incorrectly highlighted regions) and become less vigilant.<br />
<br />
I’ve heard many supporters of CAD claim that the reason for the negative results in clinical studies is that “people just aren’t using the CAD as it was intended,” which is both accurate and absurdly naive as far as defenses go. Yes, radiologists become less vigilant when they use CAD. It is not surprising, and it is not unexpected. It is inevitable and unavoidable, simply the cost that comes with working alongside humans. </blockquote>
<div>
<br />
There you go. Some food for thought. <span style="background-color: white; font-family: "arial" , "helvetica" , sans-serif;"> </span></div>
</div>
Dalaihttp://www.blogger.com/profile/17775491711029994911noreply@blogger.com0tag:blogger.com,1999:blog-10485390.post-53750135191495987212019-04-01T00:00:00.000-04:002019-04-01T10:28:09.567-04:00Rad-PAss: The Robot Radiology Physician AssistantFor the past many years, radiologists have lived in fear of AI. There are those who complain as well about radiological mid-levels, nurse-practitioners, physician assistants, etc., thinking that they, too, will encroach upon our territory. As you know from my previous entries on the subject, I personally don't buy into those fears. Artificial Intelligence and human helpers represent nothing more than assistants for us, ways to do our jobs better and faster. They will not replace us, I promise you.<br />
<br />
As with most things in this business, technology marches on, and we see progress of a sort we could not even imagine a few years ago. I am proud to announce today that thanks to a consortium of industry and intellectual powerhouses, including IBM, Facebook, the University of Maryland, the ACR, Johns Hopkins University, US Robotics, Harvard University, and the Sirius Cybernetics Corporation, we now have the next step in the evolution of our profession, <i>The Robot Radiology Physician Assistant</i>:<br />
<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgBUJS-Bxv5_5Szln1lA1K5XRZQUZm9-4zDA4jqQ5OkpkEc0WtZXe-51vF-CrsdGDakxKqaiR_xBox0Hq6YnO9Vt6PuYKB5Z15mq_Ty4l3DKeqa7FChOsl59oBrFnsId2s6glom/s1600/RobASS+copy.psd" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="578" data-original-width="928" height="396" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgBUJS-Bxv5_5Szln1lA1K5XRZQUZm9-4zDA4jqQ5OkpkEc0WtZXe-51vF-CrsdGDakxKqaiR_xBox0Hq6YnO9Vt6PuYKB5Z15mq_Ty4l3DKeqa7FChOsl59oBrFnsId2s6glom/s640/RobASS+copy.psd" width="640" /></a></div>
<div class="" style="clear: both;">
<br />
<br />
It was only a matter of time until technology caught up to our needs, and here you see it in the flesh, er, silicon. We needed a non-threatening piece of machinery that could at once process images and help with those mundane radiological chores such as slinging barium, sticking needles, and shoving catheters. The Robot Radiology Physician Assistant, affectionately known as Rad-PAss, is the embodiment of these needs, a jack-of-all trades, of whom WE are the master. </div>
<div class="" style="clear: both;">
<br /></div>
<div class="" style="clear: both;">
Rad-PAss's training is second to none, having been fed the entire body of radiological literature, textbooks, journals, videos of CME meetings in Hawaii, and even the dozen or so remaining pieces of film that have not yet been rendered down for their silver content. He went through "residency" with famed University of Maryland radiologist and AI guru Dr. Eliot Siegel, which took Rad-PAss about an hour. After this, Dr. Siegel certified his performance, also noting that he was much more personable than many human residents.<br />
<br /></div>
<div class="" style="clear: both;">
<br /></div>
<div class="separator" style="clear: both;">
</div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiXTcT-TmIqi4wr__6s97bTqXJVjUhEjyTzLHwhToXaOUtQb7XiYMUoTFNjtWC5IU-LMkeR_FbLbBEyNnsx2-sR_3VBHIOHNWFndfBFLfku1O_MBHlUaR3j8dB5Bgyr2DEJtaGO/s1600/Siegel+and+robot+copy.psd" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="720" data-original-width="1280" height="360" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiXTcT-TmIqi4wr__6s97bTqXJVjUhEjyTzLHwhToXaOUtQb7XiYMUoTFNjtWC5IU-LMkeR_FbLbBEyNnsx2-sR_3VBHIOHNWFndfBFLfku1O_MBHlUaR3j8dB5Bgyr2DEJtaGO/s640/Siegel+and+robot+copy.psd" width="640" /></a></div>
<div class="separator" style="clear: both; text-align: center;">
<br /></div>
<div class="separator" style="clear: both;">
<br /></div>
<div class="separator" style="clear: both;">
Rad-PAss can be deployed in multiple configurations. Here, we see him set to interface with the latest edition of GE's Universal Viewer PACS. With some luck, it will remain operational for the 3 milliseconds Rad-PAss requires to analyze today's workload. He will then assign preliminary reports to be reviewed and corrected if necessary by the radiologist. (So far, Rad-PAss has made no errors in interpretation, but we never say "never" in this business.) The robot can be loaded with any and all of the latest AI algorithms, which he will self-evaluate delete those he finds unsuitable or beneath his dignity. </div>
<div class="separator" style="clear: both;">
<br /></div>
<div class="separator" style="clear: both;">
<br /></div>
<div class="separator" style="clear: both;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi_RYWbdOt9sWIs4r-rGi17OmLuq3qiKFkFJDxi3BBrZv84wKeQv7k1gDnC0oSXYPZecgxl8-XAYDNhuxmE1alYcWEzOqK5KTwXfNfduCotp7kKPI2cpyx8Sog2zzgtdz6Iov29/s1600/robomultimonitor.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="581" data-original-width="681" height="545" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi_RYWbdOt9sWIs4r-rGi17OmLuq3qiKFkFJDxi3BBrZv84wKeQv7k1gDnC0oSXYPZecgxl8-XAYDNhuxmE1alYcWEzOqK5KTwXfNfduCotp7kKPI2cpyx8Sog2zzgtdz6Iov29/s640/robomultimonitor.png" width="640" /></a></div>
<div class="separator" style="clear: both; text-align: center;">
<br /></div>
<div class="separator" style="clear: both; text-align: center;">
<br /></div>
If you prefer, Rad-PAss can sit beside you in the reading room and look over your shoulder, just like the lawyers and some of your partners do, but he is on YOUR side!!<br />
<div>
<br /></div>
<div>
<br />
<div class="separator" style="clear: both; text-align: center;">
</div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjgKsbmREetK_Dp-HZ5pnxY7c2kv0a-eOhLihEpGH0-4-sWtiJOz9q86Roq9P9mswlW4cKV0Pbe4jadP7vaavIkTOZW6d3o4QbcFUwG5ZU1eHdM8rgGOU-DMkTOVZknaVCIGPdV/s1600/ReadingRoomRobot+copy.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="456" data-original-width="603" height="301" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjgKsbmREetK_Dp-HZ5pnxY7c2kv0a-eOhLihEpGH0-4-sWtiJOz9q86Roq9P9mswlW4cKV0Pbe4jadP7vaavIkTOZW6d3o4QbcFUwG5ZU1eHdM8rgGOU-DMkTOVZknaVCIGPdV/s400/ReadingRoomRobot+copy.jpg" width="400" /></a></div>
<div class="separator" style="clear: both; text-align: center;">
<br /></div>
<br />
Of course, the most exciting possibilities presented by the Rad-PAss technology are to be found in the realms of fluoroscopy. Imagine turning over the drudgery of barium studies to an assistant that does not have to worry about radiation exposure! The modified delivery apparatus includes pressure sensors to optimize patient comfort, ummmmm, well, minimize <i>discomfort</i>.<br />
<br />
<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
</div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEilJB-_bY4V-mDqZJgliaeB7bnhSjv6lzG7eAPSBHnbCNjFXLQ6yGGK41cvPBTY21LdI3Qo5UwdwuwEZf66vrY79ooe0OFfks41-7JxVM51h6P9tFAqUUpkcs8MGTRW6iZQFmuE/s1600/roboBE+copy.psd" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="449" data-original-width="306" height="640" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEilJB-_bY4V-mDqZJgliaeB7bnhSjv6lzG7eAPSBHnbCNjFXLQ6yGGK41cvPBTY21LdI3Qo5UwdwuwEZf66vrY79ooe0OFfks41-7JxVM51h6P9tFAqUUpkcs8MGTRW6iZQFmuE/s640/roboBE+copy.psd" width="435" /></a></div>
<br />
<br />
And for the IR guys, how about a catheter-jockey assistant that can pounce on a bleeder faster than you can? Here ya go:<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<br /></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjOGEPgsj5jUwNsLaXZcUgZiEHYJr80bW67vbRqGN4WhMUBHZGadQ0h1k2lPG-KhxLwvo5-oePI8r_yypTodC3oNpzCoLwR9dGXtdhq9u9olCP2s2HcV8dL-kQ3hUNumU_e5Le5/s1600/roboIR+copy.psd" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1063" data-original-width="1600" height="424" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjOGEPgsj5jUwNsLaXZcUgZiEHYJr80bW67vbRqGN4WhMUBHZGadQ0h1k2lPG-KhxLwvo5-oePI8r_yypTodC3oNpzCoLwR9dGXtdhq9u9olCP2s2HcV8dL-kQ3hUNumU_e5Le5/s640/roboIR+copy.psd" width="640" /></a></div>
<br />
Suffice it to say, a brave new world dawns TODAY in Radiology. Do mark <i>this date</i> down in history!<br />
<br />
<br />
<br />
<span style="font-size: xx-small;"><i>Legal disclaimer: Robot images courtesy of ESET.com. Neither Dr. Siegel nor any of the institutions mentioned above have anything to do with this, or me, and are included here solely in a fictional manner. And if you didn't already realize that, you haven't checked the date of this entry. </i></span></div>
Dalaihttp://www.blogger.com/profile/17775491711029994911noreply@blogger.com1tag:blogger.com,1999:blog-10485390.post-31110116373834293982019-03-27T14:07:00.002-04:002019-03-27T14:07:48.984-04:00A Capitalist Went To Cuba...<div class="separator" style="clear: both; text-align: center;">
</div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgEFMAqq6mpzb_IrEhbp9zEqU_aKzFOPFIM7EgjZTxirjMtuDlahvgBpKyFb8zKYa4RKMoiEAVu5Tkk138hMxXa_FCNX_ciSVCJNPb_AZon5mkipM4p0Jbyabn-Q3otlhy1j6va/s1600/DSCN0047.JPG" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="1200" data-original-width="1600" height="300" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgEFMAqq6mpzb_IrEhbp9zEqU_aKzFOPFIM7EgjZTxirjMtuDlahvgBpKyFb8zKYa4RKMoiEAVu5Tkk138hMxXa_FCNX_ciSVCJNPb_AZon5mkipM4p0Jbyabn-Q3otlhy1j6va/s400/DSCN0047.JPG" width="400" /></a></div>
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgQay3fx0buK5BFYmpm8ZNZxFEHZ9ip80OzjXxpvX4Ao1eudfsOtRwcxA_cO4Vl4fsF2QF12HJh0IF9Mvv6nZINga31Fpg4a6CywQe4svb6Vxhmfe5kmmkBSEsRo6Hx4KYRxDJQ/s1600/DSC08833.JPG" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="901" data-original-width="1600" height="225" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgQay3fx0buK5BFYmpm8ZNZxFEHZ9ip80OzjXxpvX4Ao1eudfsOtRwcxA_cO4Vl4fsF2QF12HJh0IF9Mvv6nZINga31Fpg4a6CywQe4svb6Vxhmfe5kmmkBSEsRo6Hx4KYRxDJQ/s400/DSC08833.JPG" width="400" /></a><br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjEkh9BcmWC1HnCP2-dv2Ei2NjX1rVH0WzbXjNWeobq-KDYbnh_6n7a6sW5Y2-j-lpJdmQvxY6QNu__nilnDHP1LlyBzTWhZdddVoX5KpUEIzYOd2ml4P1-DuHKPt6sNxKg8O7M/s1600/DSCN0061.JPG" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="1200" data-original-width="1600" height="300" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjEkh9BcmWC1HnCP2-dv2Ei2NjX1rVH0WzbXjNWeobq-KDYbnh_6n7a6sW5Y2-j-lpJdmQvxY6QNu__nilnDHP1LlyBzTWhZdddVoX5KpUEIzYOd2ml4P1-DuHKPt6sNxKg8O7M/s400/DSCN0061.JPG" width="400" /></a></div>
<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjEfyHxDFbNRv8AugF58LRyPGXKhN6KIpfXc6h86BIjzNWWm7tJL_OJDYN8zEbbzH6DcgukhpLfazRSTWWnSr-LbJVkSM6nIgy9WsXEfJpub5qoWJZJIDBGan0WEDvpUqurhU2A/s1600/DSC08658.JPG" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="901" data-original-width="1600" height="225" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjEfyHxDFbNRv8AugF58LRyPGXKhN6KIpfXc6h86BIjzNWWm7tJL_OJDYN8zEbbzH6DcgukhpLfazRSTWWnSr-LbJVkSM6nIgy9WsXEfJpub5qoWJZJIDBGan0WEDvpUqurhU2A/s400/DSC08658.JPG" width="400" /></a></div>
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgbsFeqznaLsoeRrzZysugJJcEN_M2k5RXBRV3jD0A7ZRAoEE4w7AP0Ugz665Ve-EuTLoTM4dWEcvfSENYcN8zTFEBqt1s4xT8-SVNHUaVQIaiKAttfbYjzV5eMKzEu-xnvcoK2/s1600/DSC08795.ARW" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="900" data-original-width="1600" height="225" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgbsFeqznaLsoeRrzZysugJJcEN_M2k5RXBRV3jD0A7ZRAoEE4w7AP0Ugz665Ve-EuTLoTM4dWEcvfSENYcN8zTFEBqt1s4xT8-SVNHUaVQIaiKAttfbYjzV5eMKzEu-xnvcoK2/s400/DSC08795.ARW" width="400" /></a></div>
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjTWUw-sYUE5Xy9E_xcfKc4P5M2hD-E3RMGHFxYXUDE-oG-SHEuVgdyJ6XAdlGMS0_U9-KEyWiVv6SaQoX0ZJX6Hx4Uwy8dTpZvFqovxI0jhyphenhyphen2dmJyp5AyvCEYpKJjUcNDOqHXV/s1600/DSCN0089.JPG" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="1200" data-original-width="1600" height="300" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjTWUw-sYUE5Xy9E_xcfKc4P5M2hD-E3RMGHFxYXUDE-oG-SHEuVgdyJ6XAdlGMS0_U9-KEyWiVv6SaQoX0ZJX6Hx4Uwy8dTpZvFqovxI0jhyphenhyphen2dmJyp5AyvCEYpKJjUcNDOqHXV/s400/DSCN0089.JPG" width="400" /></a></div>
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjIGH_XiCBIb8nXVsF8kT8VzGXpKZn4gd2vOppW2CkQwtGBWcq4T5tfgkdepYg_5uzJmw2MIhc6PZdOibxVlJ7_ObO2d6qzbgYZB0Fcky3YeF0JHGYcseiv63-ECgUsT0E748Na/s1600/DSC08831.JPG" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="901" data-original-width="1600" height="225" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjIGH_XiCBIb8nXVsF8kT8VzGXpKZn4gd2vOppW2CkQwtGBWcq4T5tfgkdepYg_5uzJmw2MIhc6PZdOibxVlJ7_ObO2d6qzbgYZB0Fcky3YeF0JHGYcseiv63-ECgUsT0E748Na/s400/DSC08831.JPG" width="400" /></a></div>
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi5A3_ipKLNbjdlBPPwiEabqJYChnRLeE0lOHiX-rRWNY7BQjECvcCY3IoGZzZxSuy34gbsW4_H6g-aJErStab7h3VYCdCY8tipoRTbh6pq8LmiqsWUrPD6wpoD7QPkt6btgSsN/s1600/DSC08849.JPG" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="901" data-original-width="1600" height="225" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi5A3_ipKLNbjdlBPPwiEabqJYChnRLeE0lOHiX-rRWNY7BQjECvcCY3IoGZzZxSuy34gbsW4_H6g-aJErStab7h3VYCdCY8tipoRTbh6pq8LmiqsWUrPD6wpoD7QPkt6btgSsN/s400/DSC08849.JPG" width="400" /></a></div>
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiCpErDkdosH2ouaRWLwxL2-W-1SA_Q7gakBKDzPS_Z3za0DGOzJ4zRtyDa9xiPdzN5wO9om32fahxpb1MXKle2Ozl8MeUJHLN3aFp_rNK_jXrvs1YA4MqBoiX7QSwYNG8jFAtS/s1600/DSC08864.JPG" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" data-original-height="1600" data-original-width="901" height="400" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiCpErDkdosH2ouaRWLwxL2-W-1SA_Q7gakBKDzPS_Z3za0DGOzJ4zRtyDa9xiPdzN5wO9om32fahxpb1MXKle2Ozl8MeUJHLN3aFp_rNK_jXrvs1YA4MqBoiX7QSwYNG8jFAtS/s400/DSC08864.JPG" width="225" /></a></div>
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEge-i6T6xGz4M3de4R3bMsFTtAkBOZhx9M7w64hujqRRJ_SsdI_iFnXB_9_g5w7zzC46GKog1X5QGPXekbLaQJhF19RRyQj_xYpc_Xfz4F_8J6ZJX9vNqEFYk3Fe7Daepcg6p86/s1600/DSC08624.ARW" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="900" data-original-width="1600" height="225" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEge-i6T6xGz4M3de4R3bMsFTtAkBOZhx9M7w64hujqRRJ_SsdI_iFnXB_9_g5w7zzC46GKog1X5QGPXekbLaQJhF19RRyQj_xYpc_Xfz4F_8J6ZJX9vNqEFYk3Fe7Daepcg6p86/s400/DSC08624.ARW" width="400" /></a></div>
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjbQc9_lMdmKbMQMZQQFohopfaPoQAc-hEEBAcHstP_v2ZVo3e3AIJ1wSBPA62zUfJBxeEOeGSbh_oE4RcrgTVY-wm1IhekD3HFny4CDDHbj2GHMJzUCX690_kTN-KXEaMHbmfb/s1600/DSC08663.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1600" data-original-width="901" height="640" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjbQc9_lMdmKbMQMZQQFohopfaPoQAc-hEEBAcHstP_v2ZVo3e3AIJ1wSBPA62zUfJBxeEOeGSbh_oE4RcrgTVY-wm1IhekD3HFny4CDDHbj2GHMJzUCX690_kTN-KXEaMHbmfb/s640/DSC08663.JPG" width="360" /></a></div>
<div class="separator" style="clear: both; text-align: center;">
<br /></div>
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhgqbw4xnP7sP3p4dOHFsB1CCUZyJHdrWPmmN0sO9PrfPghPOyub60A2GDhCkGwS6bTvSRav7bUtvxyIkdh08Pz1TePyIrvsaVkbtdnCF4MTBDR_l3RJtJY0nykfbqaGyqL54vt/s1600/DSC09068.JPG" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="901" data-original-width="1600" height="360" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhgqbw4xnP7sP3p4dOHFsB1CCUZyJHdrWPmmN0sO9PrfPghPOyub60A2GDhCkGwS6bTvSRav7bUtvxyIkdh08Pz1TePyIrvsaVkbtdnCF4MTBDR_l3RJtJY0nykfbqaGyqL54vt/s640/DSC09068.JPG" width="640" /></a></div>
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiOLtAJXQ_9jW1RcEc3UqUU_ZF0SvG_Ajso8YHjFr-BSMfhUhfA-KDSc_vAkXpVjvkVRKg8fEMu66-5i-MgrTIFj5u4kqx5otmpyEqVIfG6oyEXlhJqcMSiN3PO_0zgCNJQfobg/s1600/DSC09106.JPG" imageanchor="1" style="clear: right; float: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" data-original-height="901" data-original-width="1600" height="225" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiOLtAJXQ_9jW1RcEc3UqUU_ZF0SvG_Ajso8YHjFr-BSMfhUhfA-KDSc_vAkXpVjvkVRKg8fEMu66-5i-MgrTIFj5u4kqx5otmpyEqVIfG6oyEXlhJqcMSiN3PO_0zgCNJQfobg/s400/DSC09106.JPG" width="400" /></a></div>
<br />
Mrs. Dalai and I continue to travel to weird and wonderful places, and with me being officially retired, we hope to do so even more often. Cuba has always intrigued me, and I had even strongly considered joining a religious mission trip here some years ago. Yes, there is a very small, but very vibrant Jewish community in Cuba. We never did make <i>that</i> trip, but we are now circumnavigating the island nation on a very nice cruise ship. While other ships have made the run, this is the first visit for our particular liner, and I feel a bit like a pioneer. Our first stop was in Santiago, very near Guantanamo, then to Cienfuegos with a side trip to Trinidad, and we end the journey in Havana.<br />
<br />
I am very taken with this place. The land itself is spectacular, mountainous with pristine beaches almost ringing the island. The three cities on the itinerary all have incredible natural bays around which they grew. Someday, this will be a paradise, but I'm glad to have seen it before there is a Starbucks on every corner. And I promise that <i>will</i> happen. Such beauty only a stone's throw away from Key West, Florida, will not go unnoticed for long.<br />
<br />
Yes, Havana is only 90 miles (well, <i>93</i> to be precise) from the United States. Ninety miles and about 50 years away. Much of what you've heard about this place is accurate. It is Socialist, and it is poor. <i>Very</i> poor. Many, if not most buildings are in need of repair, there is trash in the streets (perhaps less than in other big cities, but still...) and there are any number of beggars. We are told there is no crime to speak of, and I hope we don't find out otherwise.<br />
<br />
You can look up Cuba's bloody past yourself, but suffice it so say that the citizens have never had an easy time. Its early history contains savage native tribes, and being owned by one colonial power and then another. In the mid-portion of the last century, Batista, the pre-Revolutionary tyrant, supported by the US until near the end of his reign, tortured the people and set the stage for Fidel Castro's <i>Revolucione</i>. Of course, the subsequent regime has not had a stellar human rights record, either. Since I'm here in country, let's not get into that right now. It's all out there on the internet.<br />
<br />
We have only had close contact with our tour guides, who work for the government-owned tour company. Most everything here IS government-owned, although there are many tiny private businesses. Many rent out rooms, or operate small restaurants out of their homes. But if a business becomes wildly successful, the government will nationalize it. The standing philosophy suggests that a business should not become so wealthy as to have the means to influence the government. Right.<br />
<br />
Our guides were honest with us to the extent that they were allowed, or so it seemed, anyway. To a man (or woman) they all admitted that their society is not perfect. This is pretty obvious. They did tout the fact that there is universal health care (but did not comment on its quality) and all mentioned the safety-net of a monthly <a href="https://en.wikipedia.org/wiki/Rationing_in_Cuba">ration card</a> that would provide rather less than a month's requirements. Our guides did not tell us how much <i>they</i> made, but did say that a teacher might make $20 US/month, and a high-production torcedor (cigar-roller) in one of the state-owned factories might make up to $200/month. I can only imagine what the Cubans think of us spending what is for them over a years' salary on a box of Cohibas. (Yes, I did! You can't go to Cuba and NOT buy cigars...perfectly legal to bring them home!)<br />
<br />
We did visit a cigar factory in Cienfuegos. They make cigars sold under a number of brands, and I haven't a clue which were being rolled that day. We weren't allowed to take photos, sadly, and there was a factory "guide" (handler would be a better term) who followed our group to enforce that. Even so, one of the torcedors (who are mostly ladies, by the way) handed me a freshly-rolled beauty and suggested I put it in my pocket. Mrs. Dalai suggested otherwise, and I sadly gave it back. I hope I did not offend...the ladies are on production, and she was giving me a gift from her own pocket. But with the handler watching, I figured it might get her in trouble.<br />
<br />
As a group from a cruise ship, I think we were monitored minimally, if at all, by the Cuban government, although I'm told by friends in Florida that people travelling as individuals, technically no longer possible, are closely watched. I wandered around Old Havana looking for the best cigar deals with no obvious tail. In fact, I really got the feeling that the Cubans couldn't care less about a bunch of elderly Americans (average age on our cruise was mummified) unleashed on their nation. I had some illusion that the US government might be more interested in our travel to this once-forbidden destination, but upon arrival back at the cruise terminal in Miami, our encounter with Customs consisted of a brief glance at our passports, and a "Welcome home!" So much for pretending to be a smuggler.<br />
<br />
Of all the things told to us by our guides, here is what I found most poignant:<br />
<br />
<blockquote class="tr_bq">
I am telling you this as Jose' (not his real name) the man, not Jose the guide. We were amazed and thrilled when Mr. Obama came here. We didn't believe it would happen until we saw it ourselves. We are sad that Mr. Trump has reversed some of what had changed, but we hope he, too, will come here and see that we want to be your friends.
<br />
<br />
Some of you have asked me how I like living under Communism. I would LOVE to live under Communism, where everything would belong to everybody. You could drive a car and park it when you are finished, and then I would get in and drive it somewhere else. That would be perfect. But what we have in Cuba is NOT Communism, it is Socialism. And it doesn't work. </blockquote>
<br />
While I don't agree with his assessment of Communism, he appears to be quite correct about Socialism.<br />
<br />
I do have some sad observations about my fellow American travellers. As I mentioned, they were mainly older, some quite a bit older. We were definitely in the youngest quintile, and probably the youngest decile of passengers. And we are not spring chickens anymore. I've railed before about waiting to take that trip of a lifetime until the end of your lifetime, and there were a few of those on board. Still, most of the rest of us were able-bodied, not that Cuba requires any great vigor to visit.<br />
<br />
You've heard about the entitled Millennials and their horrid behavior. Well, they had to learn it somewhere, and I think I've discovered the source. I have never been as embarrassed by the behavior of my fellow Americans as I was on this trip. While the majority were gracious, courteous, or at least civil, a good number of the old folks were cranky, whiny, pushy, and downright unpleasant to be around. I thought for a time I might be in a bad remake of Snow White and the Seven Dwarves, in this case, "Snowflakes and the Seven Statins". Frankly, I saw a level of anger and even contempt among this bunch which I don't recall seeing before. Perhaps as I get older myself, I find this stuff more obvious and less tolerable. These folks would cut in lines (not nice when you are waiting for a tender in 95-degree heat to take you back to the ship) and grouse about everything. Get between them and someplace they want to be, even if it means they would only have to take an extra step to go around, and you'll be the recipient of a very loud and very irate "EXCUSE ME!!!!!" I refrained from responding, 'you're excused". I don't know if these people have chronic pain syndromes, or they are just rich and spoiled, and expect the world to kowtow to them. One would think touring a poor nation like Cuba would bring home the message of just how lucky we all are to have what we have and to be able to go back to it. Or not.<br />
<br />
Compounding the joy, there was a custom among some from a certain part of the U.S. to (loudly) describe in great detail everything going on around them in real time to their companions, as if the latter were not seeing the same things at the same time, peppered of course with appropriate color commentary. Maybe the rest of us would rather experience the experience for ourselves? That's too bad.<br />
<br />
Be that as it may.<br />
<br />
I do urge you to visit Cuba should the opportunity arise. You won't regret it. Bring me back a Trinidad if you wouldn't mind...<br />
<br />Dalaihttp://www.blogger.com/profile/17775491711029994911noreply@blogger.com0tag:blogger.com,1999:blog-10485390.post-26164503052304956522019-03-27T08:44:00.002-04:002019-04-01T09:54:47.811-04:00"Ramblings On Radiology And The Job Market"<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgWyFCVoffSPloqU1GciBSUnP6uscNTuXhwFBGw7D9mJVcfpvyZi9IpNfGUHJQjbEhVNAJSaphQ6a2NSSR5mE39Qi0xay48vK4UX1msMmgeLFXefKWfr-g7Usl5PDPKyyTHucoK/s1600/diagnostic-radiology_1140x400.jpg" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="400" data-original-width="1140" height="224" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgWyFCVoffSPloqU1GciBSUnP6uscNTuXhwFBGw7D9mJVcfpvyZi9IpNfGUHJQjbEhVNAJSaphQ6a2NSSR5mE39Qi0xay48vK4UX1msMmgeLFXefKWfr-g7Usl5PDPKyyTHucoK/s640/diagnostic-radiology_1140x400.jpg" width="640" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;">Image courtesy HoustonMethodist.com</td></tr>
</tbody></table>
<i><br /></i>
<i>Dalai's note: Daniel Corbett is a Radiology business consultant who has posted incredibly useful information on Aunt Minnie as long as I've been there. This opinion piece should be mandatory reading for all in the field.</i><br />
<br />
There has been much posted lately about the robust job market for radiologists. There has been wide ranging discussion about the quality of the jobs available with regards to corporate practices and teleradiology. The potential to join a group without knowing about "discussions" the group may be having with other entities is very real. As for private practice jobs I think most would agree many if not all practices are facing the same difficulties with short staffing due to increasing volume, retirements and partners leaving for greener pastures. All this adds up to an increasingly risky job market with potential for "jumping from the frying pan into the fire" for experienced radiologists or just plain getting screwed by a fellow looking for their first job. For you 2020 fellows this can be disconcerting as there are many jobs to choose from and recruiting tactics have become aggressive. Loan repayment, signing bonuses, super short partnership tracks all tell of the desperation of groups down one or more FTE's and desperately need the help.<br />
<div>
<br />
In my 30 years in radiology I have been through several swings in the job market. The radiologist shortage of the early 2000's was deep but technology leaps and radiology increased efficiency lessening the impact of short staffing. It was bad and many groups fell apart but as a specialty we got through it. This new shortage seems more intense and desperate as efficiency through technology has maxed out. We all felt safe for the last 10 years and even complained that there were too many radiologists turning radiology into a commodity. I never believed that for a second. Radiology is THE anchor specialty and cornerstone on which all healthcare relies on. There was never a question in my mind that volumes would continue to grow along with the demands on radiologists.<br />
<br />
In my mind the whole corporate radiology model is nothing more than a Wall Street attempted takeover of the most lucrative healthcare specialty. It changes nothing in the dynamic of traditional relationship between the radiologist, the medical staff referrer and the patient. Corporate radiology is an invasion of suits and greedy radiologists selling out their specialty for a cut of the pie which has been steadily declining. These corporate entities have invaded our specialty by taking advantage of the market forces which are beyond anyone's control. With a large percentage of radiologists at or near retirement age, many of which were in controlling position within their groups, it was easy for them to lure "exit strategy" radiologists with large amounts of PE money. Over the past ten years the delayed retirement of many senior radiologists created the short term surplus of radiologists which helped these entities take hold due to a ready supply of radiologists looking for work. Another aspect is the marketing power they wield with large amounts of money. The corporate groups have unlimited funds in which to hire people to call your hospitals to get an audience. They bring high powered radiologists and business people to pitch their product of efficiency, quality, technology and 24/7 sub-specialty reads to dreamy eyed administrators who are tired of hearing complaints about their private practice radiologists. The corporate groups have moved from purchasing the fat cat groups to hostile takeovers. The gloves are off and they will steal your contract from under your nose and the next thing you know you will be offered to become an employee or leave. I know this is true because I am seeing it happen in real time with several groups. It is a train wreck in slow motion.<br />
<br />
I believe no group is safe as the stated goal of these entities is total market domination. The total corporatization of radiology would be a disaster for radiologists, hospitals and patients. These corporations must be fought at every level to keep radiologists as autonomous clinical and business entities. Radiologists should refuse to work for them even if it is for excellent pay in the perfect location. As an employee you have no control and never will. Do not trust their "partnership" sales pitch. Only in a corporate practice as an employee are you truly a commodity to be used and replaced. Only in a private practice do you truly have a say in your business and your future.<br />
<br />
The deepening shortage of radiologists is our best weapon in the fight against corporate radiology. As long as there are good private practice options the the corporate groups will struggle for staffing. Being unable to fulfill their lofty promises will be their demise. Their whole business model is dependent on properly staffing their contracts while taking a cut for investors. They throw a lot of money up front but the ROI depends on maintaining the status quo over time. I believe once the time limits for the buyouts expire those radiologists will leave causing the house of cards to collapse. Private practices must also do their part in the fight. Dishonest and dysfunctional practices must strive to be better. To remain relevant and secure private practices must do away with unfairly long partnership tracks, tiered partnerships and shady outpatient and billing schemes. Strive to be democratic and provide good professional management at all levels. Work had to promote fair practices so partners and soon to be partners feel they are treated properly and are invested in their practices. If you don't lose people you never have to recruit new people. Only by being the best option for new radiologists will private practice win over corporate radiology. Strive to improve and maintain the best relationship with your contracted hospitals. Meet regularly, immediately address issues, constantly promote your practice within the medical staff. If there are no cracks in the armor the enemy can't get in!<br />
<br />
Finally I want to advise the 2020 fellows on a few things. So far I have encountered an astonishing number of 2020 fellows who have already committed to a practice, before even starting their fellowship. I know this is because of the huge number of opportunities out there. If you get an offer with the top group in the community of your choice and you know in your heart this is THE job for you then by all means sign. But know over the next 15 months there will be plenty of other opportunities open to you. Don't be tempted to continue to interview after making a commitment. This past year I know of several fellows who reneged on groups they signed contracts with to take another job they found later. This is not how you want to start your career. When you interview you must expect the practice to put pressure on you to sign. This is normal and expected but trust me you will rarely lose an opportunity by delaying. If you interview early tell practices up front you will not make a decision until you have completed your interview process no matter how long that takes. If they chose to not interview you then you know what they are about. Do not succumb to the pressure to get a job while the market is hot. You have all the time you need. Traditional timing of interviewing after starting your fellowship and committing before the end of year or later will work out well for you. I foresee groups hiring 2020 fellows very early then continuing to recruit for an experienced candidate. If they find one they may renege on you!<br />
<br />
Radiology is experiencing rapid change again. There are some bad things to be wary of but there is also great opportunity. Knowledge is your best tool so do your homework before making changes. Seek advice from trusted sources whether your a radiologist looking to make a job change or a group looking to improve your operations and processes. Hopefully private practice will win the day and we will see a new radiology paradigm evolve over the next decade.<br />
<i><br /></i>
<i>ADDENDUM...More from Mr. Corbett:</i><br />
<br />
Private practices contracted to a hospital is the purest form in hospital based specialties. The volume generated by the hospital department will generates X in pro fees. This is the book of business available. This will vary by location and payor mix. The rads read and bill for the exams and get reimbursed creating the "pie" of net revenue. From the net revenue you need to pay the bills/expenses which usually include billing fees, accounting, legal and all the other miscellaneous costs to run the business. In some groups this can include employees and all the expenses that come with them including rent, equipment and supplies. What is left is physician compensation. Included in physician compensation are benefits and tax deductible business expenses like CME, Phones, Med mal, health, etc. What is left is W-2 which is your taxable income. <br /><span style="background-color: white; font-family: Arial, Helvetica, sans-serif;"> </span><br style="background-color: white; box-sizing: border-box; font-family: Arial, Helvetica, sans-serif;" />These expenses vary greatly by group based on size and how they choose to run the business. Some practices have high overhead due to many employees, imaging centers, own billing companies, etc. I have seen overhead percentage run up to almost 30% of collected revenue. I have also seen lean, self managed groups run as low as 9-10%. Considering a primary care practice averages 40-50% overhead, radiology is not such a bad gig. I believe the average overhead percentage for a well run private practice with no imaging centers to be around 12% which includes billing and management (legal, accounting, infrastructure). <br /><span style="background-color: white; font-family: Arial, Helvetica, sans-serif;"> </span><br style="background-color: white; box-sizing: border-box; font-family: Arial, Helvetica, sans-serif;" />Now consider a hospital employed practice. The hospital provides all the infrastructure including the billing, management and benefits. They pay the radiologists a salary and benefit package to provide service. This can be a simple model and appear to be a good deal for some radiologists as long as they are getting paid a fair market rate for a fair market volume of work. The problems with employed models is hospitals don't do well managing radiologists and the expenses get away from them. They also don't understand fair market value and its relationship to the amount of work. They often get wrapped up in silly unrealistic RVU productivity models which cause more damage than good. Also most radiologists (doctors in general) who are employed default to the lowest productivity needed to keep their job. Why work harder if you don't get paid more? This requires hospital employed models to be overstaffed which lead to higher costs (overall) to get the work done so the hospital ends up subsidizing the professional component out of the technical revenue. Some hospitals are fine with this if it is control they crave but eventually the constant turnover and internal dysfunction can cause them to fail. <br /><span style="background-color: white; font-family: Arial, Helvetica, sans-serif;"> </span><br style="background-color: white; box-sizing: border-box; font-family: Arial, Helvetica, sans-serif;" />So the original question is how can a corporate sell their model to hospitals? The answer is NEVER if there is a lean, well run private practice in place. Almost every single corporate take over happens because there is weakness with the current provider. Lack of service, poor quality or most common group dysfunction is the culprit in a private practice contract loss. Every Single Time! The corporates always sell the hospital on making their radiology provider woes go away. They are NEVER a cheaper option. They sell the hospitals on quality, technology, infrastructure, management and especially service. Also the lure of 24/7 sub specialty reads is like crack to a hospital administrator, especially dealing with a troublesome group. <br /><span style="background-color: white; font-family: Arial, Helvetica, sans-serif;"> </span><br style="background-color: white; box-sizing: border-box; font-family: Arial, Helvetica, sans-serif;" />Let me be clear about this again. The idea of skim jobs and back door financial deals between hospitals and corporate radiology are pure fantasy. Sure sometimes there are some shady deals that get them in the door but for the most part the deal must stand alone on the service provided for the revenue generated. As we all know you can only streamline, increase efficiency and cut costs so much. After that it comes down to what the radiologist gets paid. The main cost modifier for these corporate groups is through the leveraging of teleradiology but this has a hard limit. You need critical mass onsite to make any hospital run optimally. When the market was fat with radiologists they could pay less. Now that there is a shortage they must be competitive which dips into their profits. As I have been saying all along, staffing will be their downfall. If they can't afford market rate labor and maintain staffing they will fail. Once the profits decrease and losses accrue Wall Street is gone! Unfortunately when this eventually pans out there will be a large hungry black hole which will need to be addressed but that is for another post at another time. <br /><span style="background-color: white; font-family: Arial, Helvetica, sans-serif;"> </span><br style="background-color: white; box-sizing: border-box; font-family: Arial, Helvetica, sans-serif;" />Again in reality is nothing can compete with a competent well run private practice surviving on the professional component. Hospitals desire high quality reads with superb service and not providing a subsidy. In the past hospitals provided their well respected groups financial help with the supply and demand of radiologists turned. No hospital wanted their long term (functional) providers to self destruct. Usually these subsidies where tied to real data showing where the group needed help to remain competitive. When the market changed the subsidies were removed or renegotiated. The key is always fair market value and the ability to properly staff. All hospitals really desire are well led and managed groups where the radiologists are involved at all levels. If they have this they have no need to consider other options. <br /><span style="background-color: white; font-family: Arial, Helvetica, sans-serif;"> </span><br style="background-color: white; box-sizing: border-box; font-family: Arial, Helvetica, sans-serif;" />In a perfect world this should be easily attainable but too many groups are dysfunctional. Poor leadership, lack of proper infrastructure, disruptive radiologists, poor practice management, shady partnerships and billing practices, you name it, it's out there. You may think your business is yours and not known by the hospital and medical staff but you would be wrong. All your dirty laundry is out there. You know it because you know all the other physicians dirty laundry. What still amazes me is how a multi-million dollar business like a radiology practice can be properly managed by the radiologists who have no formal training in business. I know of many multi-million dollar radiology groups who are managed by former techs and some with no formal healthcare business education. Not to say some of these people are not good at what they do and are not dedicated. I have worked with some amazing practice managers but how can one person, even one with a BA or MBA in business know all there is to know about a highly complicated business like radiology? They just can't be experts at everything. It still boggles my mind how many groups have little to zero oversight of their billing companies or operations. When was the last time your group audited your billing company? We have found hundreds of thousands of dollars being lost over many years. BTW this is another area where the corporates will have an advantage. They know where EVERY dollar is generated, collected, and spent. <br /><span style="background-color: white; font-family: Arial, Helvetica, sans-serif;"> </span><br style="background-color: white; box-sizing: border-box; font-family: Arial, Helvetica, sans-serif;" />I am always hesitant to sound like I'm marketing but I was asked how organizations like RP and Envision get their noses under the proverbial tent. My answer is and will always be the lack of organization, leadership, governance, finance and overall management of private practices. For the sake of security and protecting itself from any potential invasion, every private practice should do a top down, comprehensive, in the weeds evaluation of the way they structure, govern, lead, operate and manage their practice. <br /><span style="background-color: white; font-family: Arial, Helvetica, sans-serif;"> </span><br style="background-color: white; box-sizing: border-box; font-family: Arial, Helvetica, sans-serif;" />Healthcare is rapidly changing. We are being told to do more with less. The cost of this amazing care we have in our country can't be afforded by the majority of the population. The insurance industry is broken. They way healthcare is delivered is broken. Change is inevitable and change is where Wall Street invests heavily. Wall Street and PE money are capitalizing on the greed, dysfunction and lack of cohesion between radiologists. After all they can run your business way better than you. They will buy some and steal others. The only way to stop them is compete and be better. But the first step to recovery is learning you have a problem. I hear it all the time...our practice is great, everything runs well, we all get along, everyone loves us....just before the bus runs you over - BAM! </div>
Dalaihttp://www.blogger.com/profile/17775491711029994911noreply@blogger.com0tag:blogger.com,1999:blog-10485390.post-9022074405708406452019-01-13T18:58:00.003-05:002019-02-04T20:58:19.223-05:00Senior Discounts<div class="separator" style="clear: both; text-align: center;">
</div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi_yoDZMo_MegnxkpVHcKxhEPuUHiphsIwEV2WijA4JLN63O2_N2VfAErZiYhRJUmY5Sny0vTQDLsCyx4vC6s0ULYk97iFrnbGPVJvGX_MBNah9W2phKaux3Osoh5Ura0KV_dk9/s1600/symbol+copy.psd" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="398" data-original-width="436" height="292" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEi_yoDZMo_MegnxkpVHcKxhEPuUHiphsIwEV2WijA4JLN63O2_N2VfAErZiYhRJUmY5Sny0vTQDLsCyx4vC6s0ULYk97iFrnbGPVJvGX_MBNah9W2phKaux3Osoh5Ura0KV_dk9/s320/symbol+copy.psd" width="320" /></a></div>
<br />
On January 1, 2019, I officially retired from the position I held for 28.5 years. Let the new era begin!<br />
<br />
In the interest of transparency, I have to tell you that this was not entirely by choice, and I am assured that there was no problem whatsoever with my work. But be that as it may, my life's schedule is now pushed up just a bit. The metamorphosis from practicing physician to private citizen (and eventually, I suppose, to <i>patient</i>) is a process I had started a few years ago, when I cut back to working 26, and then 22 weeks per year, dumping call in the process. There were those who couldn't understand my action at that time, those who said I was not a "team-player" and that I was "gaming the system". I strongly disagreed then, and I still do. If anything, at part-time rates, I was a bargain for the niche expertise I provided, but the attitude betrays a level of pain, both self-inflicted and externally-sourced, that many physicians experience, but won't discuss.<br />
<br />
I'm not totally out of business, however, which is one of several reasons why I demurred on the retirement party the group wanted to give me. (They remind me too much of wakes anyway.) Our med-mal carrier allows us to work up to 60 days per year without additional tail coverage, and so I'll be able to keep my hand in the till, I mean the practice, for a while longer, and so I'm not quite gone from the old place just yet. This little reprieve gives me, at age 60, a bit longer to reinvent myself. I love travel, and had planned on doing more in retirement, but the abrupt loss of revenue (not to mention having to pay $37,000 out of pocket for health insurance and deductible) will limit that. There will be no 'round the world cruises for the foreseeable future.<br />
<br />
Some have asked: "Is it wrong to retire early from a medical career?" Some, including me, have answered, "No." "Wrong" implies that we retirees are pilfering something by going about our merry way, which is certainly not the case. As with everything else in life, this transition represents a balance; retirement obviously stops the emotional hemorrhage, the drain on our psyches and our souls inherent in this business, but we are then deprived of the many joys of healing as well. It's a tough choice...maybe I'm lucky I didn't have to make it all on my own.<br />
<br />
Retirement brings seismic changes in my personal finances, and so I've had to make some adjustments. Obviously, it's hard to know how much cash you <i>need</i> until you know how much you <i>spend</i>. To that end, I created the Google Form illustrated below, which allows the entry and subsequent monitoring of every single expenditure. Every single dollar. Every last cent. EVERY. LAST. BLOODY. CENT. I am going to have an absolute and complete handle on this if it kills me, and it just might.<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjZOC9g_UB4QRTly7lC18_fJY9cVUqrKJ2ogZyw9pKlbKpKTmSn1M-5PySYnpUUf8XNrfPHfFzK6agKfRipNPdZsB7SuHpYaWr-3BPAe5pg1C5CPdiiTguqIG-7qE4JZXPivd0l/s1600/Screen+Shot+2019-01-06+at+1.56.21+PM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1600" data-original-width="868" height="640" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjZOC9g_UB4QRTly7lC18_fJY9cVUqrKJ2ogZyw9pKlbKpKTmSn1M-5PySYnpUUf8XNrfPHfFzK6agKfRipNPdZsB7SuHpYaWr-3BPAe5pg1C5CPdiiTguqIG-7qE4JZXPivd0l/s640/Screen+Shot+2019-01-06+at+1.56.21+PM.png" width="345" /></a></div>
<br />
There are any number of fairly painless ways to save a buck. The home thermostat, for example, is now set to a reasonable 68 degrees, instead of the more comfortable 72. Should have done that years ago. I suppose when summer hits down here in the Deep South (usually sometime in late February), I'll jack it up to, oh, maybe 75? I'm already wilting at the thought.<br />
<br />
Reaching age 60 will facilitate some savings, although I had a minor intestinal disturbance when the kid at the grocery check-out announced, "And since today is Wednesday, you get the Senior Discount!" I <i>used</i> to think the average age of those taking advantage of Senior Day was dead. But hey, I'm getting pretty good at value shopping. I can tell you which neighborhood grocery has the best deal on Veuve Clicquot. What?! I may be un(der)employed, but I haven't yet reached the level of eating dog food. Or the dogs. Yet.<br />
<br />
Everyone now wants to know about the next chapter. The short answer is that the book is far from finished, and I'm just starting to type the first word or two of the first line of that next chapter. I mentioned above that I will continue to work for the old practice for a while. Of the 60 days I'm allowed this year, I have 29 booked so far, and that will at least help with health insurance. In addition, I've been asked to give a talk to our state Nuclear Medicine Society meeting in a few months, and I've found that the best way to keep my skills sharp is to share them.<br />
<br />
In the meantime, there is quite a bit to do around the house. My two little dogs alone can keep me quite busy; their favorite activity is requesting to go outside so they can come back in again. The laundry basket magically fills itself up at least every other day, which must be addressed. In case you wondered, I haven't ruined anything in years. No, I don't wash it all in hot water.<br />
<br />
There are drawers that need dumping, their contents sorted and reloaded, stuff to be taken to Goodwill, and things to be moved from one shelf to another. Like the gym ad, I find myself picking things up and putting them down again, although the objects do end up in other places, thank you. And the yard always needs something done to it. I do have a service, but they don't weed, and they have a very bad habit of blowing leaves into the bushes, thinking I won't notice. I've been known to use a Shop-Vac to literally vacuum out the azaleas; the last time I did that I accumulated a pile of leaves about 3 feet high, which the yard guys charged extra to haul away, even though it was all their fault to begin with. And I seem to have discovered magic weeds (no, not <i>those!</i>) that happily ingest and thrive on Round-Up. All that exposure to a potential carcinogen for nothing.<br />
<br />
My main achievement in retirement so far has been the establishment of the "For Better Or Worse But Not For Lunch" club:<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiiSj1nV0MX8cYnWAF-a_DdCDz18qY2ewh_wcg8uMYHonlSb71uYRFYN-hpEREKVUTSzT1iyMy5HbGkMSMoZDAnsviBW0mdjoyLXmO6jC7nxJzyxnpUgmKM9F5Ns5o6EX2pTTZW/s1600/FBOWBNFL+copy+copy.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="168" data-original-width="890" height="75" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiiSj1nV0MX8cYnWAF-a_DdCDz18qY2ewh_wcg8uMYHonlSb71uYRFYN-hpEREKVUTSzT1iyMy5HbGkMSMoZDAnsviBW0mdjoyLXmO6jC7nxJzyxnpUgmKM9F5Ns5o6EX2pTTZW/s400/FBOWBNFL+copy+copy.jpg" width="400" /></a></div>
<br />
"Club" is perhaps too fancy a word for a gathering of a bunch of retired guys who need to get out of the house once in a while, but call it what you will, we had a great time at the first lunch meeting. The plan is to reconvene on the second and fourth Tuesdays of the month. Assuming I make them all, that leaves only 331 more days to fill...<br />
<br />
And fill them I shall. There are still a few trips I've had on the books since before the Lessened Event, and you'll eventually see pics here from some far-flung places. (Teaser...several destinations are islands, one is in a desert, and one will involve <i>Star</i>-struck photos with Famous People!)<br />
<br />
The elephant in the room is, of course, what I will REALLY do when I grow up, since there doesn't seem to be a way to avoid adulting at this late date. Honestly, nothing seems to fit perfectly. I've tried writing, but obviously I haven't been quite as motivated as I once was. Maybe that will change. And while I enjoyed my mission trips, I found they are more for the young and strong, and those who think well on their feet, even after multiple sleepless nights. I don't want to do locums, and the VA here needs to fill several full-time spots before I could even be considered for a part-time NM position. I've sent out some feelers to various PACS and equipment vendors, but surprisingly, they are not yet squabbling with each other to be the first to have Doctor Dalai on the payroll.<br />
<br />
No doubt the real answer is something else I haven't considered or even thought of as yet.<br />
<br />
So, for the moment, I'm going to wallow in my (mostly) retired status. I'll sleep late on occasion, and be the best house-husband I can be. I've been advised by other retired docs to just relax and enjoy it for a while. The proper path will become obvious. Eventually.<br />
<br />
But for now, you must excuse me...the clothes dryer just buzzed...Dalaihttp://www.blogger.com/profile/17775491711029994911noreply@blogger.com5tag:blogger.com,1999:blog-10485390.post-2963723629057487392018-08-18T20:39:00.003-04:002019-01-10T17:49:08.270-05:00The Abscopal Effect<br />
<div class="separator" style="clear: both; text-align: center;">
<br /></div>
<div class="separator" style="clear: both; text-align: center;">
<br /></div>
<div class="separator" style="clear: both; text-align: center;">
<br /></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://4.bp.blogspot.com/-GG9LCT3NMzo/W3iivqiteUI/AAAAAAAAEgA/BoOInpgaRms65nyG9d3x-37Kwjtu1_j3wCLcBGAs/s1600/possible.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="228" data-original-width="222" height="400" src="https://4.bp.blogspot.com/-GG9LCT3NMzo/W3iivqiteUI/AAAAAAAAEgA/BoOInpgaRms65nyG9d3x-37Kwjtu1_j3wCLcBGAs/s400/possible.png" width="389" /></a></div>
<div class="separator" style="clear: both; text-align: center;">
<br /></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://2.bp.blogspot.com/-EpQiVcU_CT0/W3iivzOdkPI/AAAAAAAAEgE/TJWHAEZJcJcDxMb0QRUoWXs8nHjaZn9jgCLcBGAs/s1600/arthurcclarke1-2x.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="630" data-original-width="1200" height="210" src="https://2.bp.blogspot.com/-EpQiVcU_CT0/W3iivzOdkPI/AAAAAAAAEgE/TJWHAEZJcJcDxMb0QRUoWXs8nHjaZn9jgCLcBGAs/s400/arthurcclarke1-2x.jpg" width="400" /></a></div>
<div class="separator" style="clear: both; text-align: center;">
<br /></div>
<div class="separator" style="clear: both; text-align: center;">
<br /></div>
<div class="separator" style="clear: both; text-align: left;">
In the waning years of my career as a Nuclear Radiologist, I have become somewhat more jaded than I was as a younger doc. When you see cancer and other diseases fifty times a day, sometimes getting better, sometimes getting worse, that's bound to happen. Of course, I far prefer reporting improvement, but relapses are also part of this job. The oncologists wander into the reading room every few minutes, or so it seems, anyway, to look at their patients' scans (the gantry is generally still warm). If the news is bad, I will tell them in all honesty that I admire the strength it will take to deliver the bad news. On those occasions I'm quite content to sit in the dark and stare at my 8 monitors.</div>
<div class="separator" style="clear: both; text-align: left;">
<br /></div>
<div class="separator" style="clear: both; text-align: left;">
One day last week, one of the Med Onc's came in to the reading room with a rather odd look on his face. "You didn't read this scan, but I want you to look at it," he said, which immediately set my mind at ease. (The four most dreaded words in this business are: "<i>You read a scan...</i>") </div>
<div class="separator" style="clear: both; text-align: left;">
<br /></div>
<div class="separator" style="clear: both; text-align: left;">
He had me look first at a PET/CT from earlier in the year on this elderly patient:</div>
<div class="separator" style="clear: both; text-align: center;">
<br /></div>
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://3.bp.blogspot.com/-ufsJQaMSFms/W3ggKnX1bFI/AAAAAAAAEfo/Ad-9GqpYb10zeyvIWQ4BqeyYKj-eOSaiACLcBGAs/s1600/PET%2Bcine%2B1.gif" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="886" data-original-width="468" height="640" src="https://3.bp.blogspot.com/-ufsJQaMSFms/W3ggKnX1bFI/AAAAAAAAEfo/Ad-9GqpYb10zeyvIWQ4BqeyYKj-eOSaiACLcBGAs/s640/PET%2Bcine%2B1.gif" width="336" /></a></div>
<div class="separator" style="clear: both; text-align: center;">
<br /></div>
<div class="separator" style="clear: both; text-align: left;">
You don't need me to interpret this for you, which is a bad sign. We see several lesions in the liver, presumably metastatic spread of cancer. There is a small focus in the upper thoracic spine, and a much larger coalescence of several lesions involving the lower thoracic spine. There are other lesions, and there is (benign) calcification around the mitral valve of the heart. </div>
<div class="separator" style="clear: both; text-align: left;">
<br /></div>
<div class="separator" style="clear: both; text-align: left;">
OK...now, here is the most recent study:</div>
<div class="separator" style="clear: both; text-align: center;">
<br /></div>
<div class="separator" style="clear: both; text-align: center;">
<br /></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://1.bp.blogspot.com/-S8pAlGn7FrM/W3ggK6I-51I/AAAAAAAAEfs/cvj4Tr9bKPkeqmuOP3ppD_Gs7zfxHRfpgCLcBGAs/s1600/PET%2Bcine%2B2.gif" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="886" data-original-width="468" height="640" src="https://1.bp.blogspot.com/-S8pAlGn7FrM/W3ggK6I-51I/AAAAAAAAEfs/cvj4Tr9bKPkeqmuOP3ppD_Gs7zfxHRfpgCLcBGAs/s640/PET%2Bcine%2B2.gif" width="337" /></a></div>
<br />
<div class="" style="clear: both;">
<br />
Just about all the bad stuff is gone. Most everything we see is physiologic. (The hotspot in left upper abdomen is in the stomach, and the CT didn't show anything there, but we'll still watch it.)<br />
<br />
This isn't a particularly unusual scenario following therapy, and I complimented my friend on another successful administration of his potions and poisons. At this point, he shifted uncomfortably from foot to foot. He finally looked up and said, "But we only treated the lower spine lesion with radiotherapy. We didn't treat the other areas!" We called in the treating Rad Onc, who was equally surprised. "Wow. This would have to be an abscopal effect. I've never seen one before. There might be 20 or so reports out there..."<br />
<br />
What in the world is the "Abscopal Effect"?<br />
<br />
From the <a href="https://en.wikipedia.org/wiki/Abscopal_effect">Wikipedia</a>:<br />
<br />
<blockquote>
The abscopal effect is a phenomenon in the treatment of metastatic cancer where localized treatment of a tumor causes not only a shrinking of the treated tumor, but also a shrinking of tumors outside the scope of the localized treatment. R.H. Mole proposed the term “abscopal” (‘ab’ - away from, ‘scopus’ - target) in 1953 to refer to effects of ionizing radiation “at a distance from the irradiated volume but within the same organism.”<br />
<br />
Initially associated with single-tumor, localized radiation therapy, the term “abscopal effect” has also come to encompass other types of localized treatments such as electroporation and intra-tumoral injection of therapeutics. However, the term should only be used when truly local treatments result in systemic effects. For instance, chemotherapeutics commonly circulate through the blood stream and therefore exclude the possibility of any abscopal response.<br />
<br />
The mediators of the abscopal effect of radiotherapy were unknown for decades. In 2004, it was postulated for the first time that the immune system might be responsible for these “off-target” anti-tumor effects. Various studies in animal models of melanoma, mammary, and colorectal tumors have substantiated this hypothesis. Furthermore, immune-mediated abscopal effects were also described in patients with metastatic cancer. Whereas these reports were extremely rare throughout the 20th century, the clinical use of immune checkpoint blocking antibodies such as ipilimumab or pembrolizumab has greatly increased the number of abscopally responding patients in selected groups of patients such as those with metastatic melanoma.</blockquote>
Visually (also from the Wiki):<br />
<br />
<table align="center" cellpadding="0" cellspacing="0" class="tr-caption-container" style="margin-left: auto; margin-right: auto; text-align: center;"><tbody>
<tr><td style="text-align: center;"><a href="https://4.bp.blogspot.com/-052yrY8rrt0/W3i2UnLJVfI/AAAAAAAAEgU/LUyn_UzquK4nZHkfPK_pwwPpO5SfmSyGgCLcBGAs/s1600/Screen%2BShot%2B2018-08-18%2Bat%2B8.13.28%2BPM.png" imageanchor="1" style="margin-left: auto; margin-right: auto;"><img border="0" data-original-height="1172" data-original-width="1600" height="292" src="https://4.bp.blogspot.com/-052yrY8rrt0/W3i2UnLJVfI/AAAAAAAAEgU/LUyn_UzquK4nZHkfPK_pwwPpO5SfmSyGgCLcBGAs/s400/Screen%2BShot%2B2018-08-18%2Bat%2B8.13.28%2BPM.png" width="400" /></a></td></tr>
<tr><td class="tr-caption" style="text-align: center;"><div style="font-size: medium; text-align: start;">
"<span style="background-color: #f8f9fa; color: #222222; font-family: sans-serif; font-size: 12.3704px;">Proposed mechanism of the abscopal effect, mediated by the immune system. Here, local radiation causes tumor cell death, which is followed by adaptive immune system recognition, not unlike a vaccine.'</span></div>
<div>
<br /></div>
</td></tr>
</tbody></table>
So, this rare phenomenon probably has a scientific explanation. I'm used to seeing various cancers and other diseases cured, or at least kept at bay, including things we were taught not that long ago were "incurable". I see what was once impossible happen pretty much every day. And that's amazing enough when you think about it. </div>
<div class="" style="clear: both;">
<br /></div>
<div class="" style="clear: both;">
Arthur C. Clarke once said, "Any sufficiently advanced technology is indistinguishable from magic." While there is science behind the Abscopal effect, it is still unusual enough that I have no problem calling it a miracle. As a rare perk in my end of health-care, I had the great opportunity to show the scans to the patient herself. She and her husband and daughter took it all in with quiet faith and dignity, enough to make you cry. How many times in a career does the opportunity come along to tell someone their prayers have been answered? </div>
<div class="" style="clear: both;">
<br /></div>
<div class="" style="clear: both;">
A miracle? Maybe. After all, we did have all the bases covered. The MedOnc is Muslim, I'm Jewish, and the patient is Christian. I wonder if that sort of coming-together would work in other venues...</div>
Anonymousnoreply@blogger.com4tag:blogger.com,1999:blog-10485390.post-64345785584904528032018-07-08T21:21:00.001-04:002018-07-17T12:04:14.052-04:00A Cold-Call Email From A HeadhunterI HATE SPAM. HATE IT. With a passion. Almost as much as I hate robocalling telemarketers. I REALLY hate <i>them</i>. It would be nice if the Feds would send just one little bitty teeny-tiny cruise missile into a Bangalore call center or two. I do believe that would solve the problem.<br />
<br />
But back to email SPAM. <br />
<br />
In among the various advertisements for incredible products (that don't exist), emails from Russian women (written by burly gentlemen who probably aren't in Russia), and offers from Nigerian princes (who probably <i>are</i> Nigerian but are unlikely to be royalty), I often find messages from radiological headhunters, middle-men trying to either get me to hire someone or to put me on their list for similar cattle-calls. Now, before you get upset, I will certainly acknowledge the existence of legitimate, high-level employment agencies, who provide a service to the best candidates and groups or employers. However, any agency that acquires slots to fill and people to fill them via cold calling, and unsolicited emails, is NOT an agency I want to deal with on any side of the equation.<br />
<br />
Note: I am NOT looking for a job. I'm working 22 weeks per year, a sustainable pace, and I'm hoping to continue to do so. It is quite clear that the headhunters are fishing for anyone with a medical license and a pulse. Otherwise, why reach out to an old guy like me? I guess the fees are not age-based.<br />
<br />
My latest bemusement stems from the following communication. The company involved will remain nameless, unless someone gives me a reason to mention it...<br />
<blockquote class="tr_bq">
Subject: Re: Primary Care Providers - Can you recommend a colleague?<br />
<br />
<div style="text-align: center;">
<i>If you aren't interested, please unsubscribe rather than marking as junk.</i></div>
<br />
Good Afternoon Dr. Dalai,<br />
<br />
I wanted to follow up on the email I sent last week regarding primary care locums in your town. Do you have any time in your schedule to help? Experience with addiction desirable, but not required. Details below:<br />
<br />
(My Hometown)<br />
Mon-Fri 8:30a – 5p<br />
No afterhours, no weekend call<br />
20-30 patients per day<br />
Treating substance withdrawal<br />
<br />
Please let me know if you have any interest or know of a colleague to refer. I look forward to hearing from you!<br />
<br />
Thanks,<br />
<br />
RB - Primary Care Recruiting Specialist</blockquote>
Houston, we have some problems already. First, I'm NOT a Primary Care Provider! And marking these emails as junk is what most people correctly do with them. And.... TREATING SUBSTANCE WITHDRAWAL? Is addiction a job requirement? Or would the successful candidate have to participate in treating others? Inquiring minds want to know. Unfortunately for RB, I <i>didn't</i>. This response went out immediately:<br />
<blockquote class="tr_bq">
Hey RB....THIS IS SPAM and you have been reported to the FTC and your ISP. STOP USING BOTTOM FEEDER spamming. It will NOT work. </blockquote>
This got the attention of someone higher up in the company food-chain:<br />
<blockquote class="tr_bq">
Please allow me to apologize for any inconvenience this email may have caused you. I have performed a thorough search and found that this the only email we have ever sent to you. I am not sure specifically from where they obtained it, but your information was on a list we purchased through a major healthcare data supplier. I would posit that the message sent by RB was “Bulk” in nature rather than SPAM. We have a legitimate business offer, we didn’t send anonymously, we provided all of the necessary “Unsubscribe /Opt Out” requirements. Additionally, she did offer a referral should you know any colleagues. She did receive several positive responses and we have somebody placed already as a result of the campaign. Once again, I would like to apologize and let you know that you have been permanently removed and can expect no further communication from us<br />
<br />
Respectfully, RM, USMC ret.<br />
<br />
Vice President of Recruiting and Gov’t Ops.</blockquote>
That really made it all better. It was a legitimate business offer! Who knew!? And apparently RB lied when she said she was "following up" the earlier email that her boss RM says was never sent. I love it when someone attempts to plant false memories, don't you?<br />
<br />
While I don't generally mess with Marines, RM's justification of the low-class approach was just too much. SPAMMING is no different to the recipient than Bulk email...the messages are NOT WANTED by the vast majority of the population. Even worse, they purchased my name from a sucker list! This was not to go without challenge, although I was still being relatively nice at that point:<br />
<blockquote class="tr_bq">
Thank you. Please let me know the source of my email address so I can put a stop to this sort of thing. </blockquote>
The response came quickly:<br />
<blockquote class="tr_bq">
That I can’t do with 100% accuracy. It would have either been Billian's HealthDATA or Definitive Healthcare. I believe the two are now merged, but when we originally obtained lists, they were two separate entities.<br />
<br />
I was actually able to determine that it was Definitive. As mentioned, I have removed your email so that you won’t be on any bulk distribution lists. I would like to ask, though, if I should keep you in my database? I do occasionally have Locums Radiology work if you might be interested. If not, I certainly understand.</blockquote>
And here, I saw red. I've just made it clear that I don't want to be SPAMMED, and the gentleman keeps digging for business! I wasn't terribly nice at this point:<br />
<blockquote class="tr_bq">
I would say it took incredible gall for you to even ask that question.<br />
<br />
Please provide the name of the manager/owner of your company. I need to have a little talk with them, it seems. </blockquote>
I guess I hurt the Marine's feelings, which was not really what I wanted to do, but desperate times call for desperate measures. Here's his final communication:<br />
<blockquote class="tr_bq">
Dr. Dalai,<br />
<br />
I thought we had reached some amount of common ground after explaining my position based on one email sent to you. I aim at providing a valued service to any potential provider, hence my question relating to keeping you in the database but never sending you email. After what I thought had been worked out and we had engaged in a dialogue, it seemed normal to ask that question. There was no Impudence. I obviously now have the answer to my question. I will permanently remove any trace of you from our system and wish you all the best.<br />
<br />
Respectfully, RM, USMC ret.<br />
Vice President of Recruiting and Gov’t Ops.</blockquote>
No Impudence? Heck yes, there was Impudence! Keep me in the data base but never send me emails? Right.<br />
<br />
I guess headhunting is a brutal business, requiring the participants to climb all over each other to get clients and job slots. That's all well and good, but DON'T use SPAMMING (or cold-calling) to fill your lists. It's low-class, it's annoying, and despite the claims otherwise, I suspect positions and candidates gathered in this manner might not be the best of the best of the best. No offense to anyone hired this way; I hope you are all happy with where you are. But I PROMISE the headhunters: you are angering far more people than you are serving. Find a better way.<br />
<br />
By the way, I did get in touch with Definitive Healthcare (sales@definitivehc.com) and requested that my information be removed from their system. They promised to do so. Unless you like to be SPAMMED, I would strongly recommend you do the same.<br />
<br />
Until the next outrage...<br />
<br />Anonymousnoreply@blogger.com0tag:blogger.com,1999:blog-10485390.post-8365922115149281252018-07-06T22:01:00.003-04:002018-07-07T08:02:11.347-04:00"Despicable" GE Spins Off...Minion Healthcare?<div class="separator" style="clear: both; text-align: center;">
<a href="https://4.bp.blogspot.com/-64S9SDq4X_U/WzVf4HCL6MI/AAAAAAAAEc0/24iIe928nkEvO896hKuUAnl9IpsgO_o1QCLcBGAs/s1600/despicable%2BGE.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="450" data-original-width="308" height="640" src="https://4.bp.blogspot.com/-64S9SDq4X_U/WzVf4HCL6MI/AAAAAAAAEc0/24iIe928nkEvO896hKuUAnl9IpsgO_o1QCLcBGAs/s640/despicable%2BGE.png" width="436" /></a></div>
<br />
I couldn't let an occasion as momentous as <a href="https://www.radiologybusiness.com/topics/healthcare-economics/ge-moves-spin-healthcare-division-0">General Electric</a> spinning off its Healthcare division go without mention. As yet, the new pure-play division has no name other than GE Healthcare, which is what it used to be called before being spun. Off, that is. So I guess it's up to me to name the new baby.<br />
<br />
We all know that Siemens performed a similar excision of its Healthcare Division back in March of this year, although this was announced back in November, 2017. You may know that Siemens had a sponsoring <a href="https://insidethemagic.net/2017/06/walt-disney-company-siemens-announce-end-12-year-sponsorship-information-expected-d23-expo-2017/">relationship with Disney</a>...<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://4.bp.blogspot.com/-1LUAybgKj5g/WzYxWQr1iCI/AAAAAAAAEdA/4I1MvJoO35IKCk34UmTaBTphAk0I7oCvQCLcBGAs/s1600/siemensdisney.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="497" data-original-width="746" height="266" src="https://4.bp.blogspot.com/-1LUAybgKj5g/WzYxWQr1iCI/AAAAAAAAEdA/4I1MvJoO35IKCk34UmTaBTphAk0I7oCvQCLcBGAs/s400/siemensdisney.jpg" width="400" /></a></div>
<br />
...until October of 2017, and I have to wonder if that had something to do with the unfortunate moniker "Healthineers" applied to the new Siemens offspring. Perhaps the folks in Erlangen don't realize how odd it sounds. No offense to Siemens or to Disney, but it just doesn't click. (A bit of trivia: Few will remember that <a href="https://www.cbsnews.com/news/ge-plans-broad-push-in-healthcare/">GE </a> once touted a "Healthymagination Initiative" worthy of <a href="https://en.wikipedia.org/wiki/Figment_(Disney)">Figment</a> himself.)<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://2.bp.blogspot.com/-j1zhiwYsG20/Wz7LmF0-rYI/AAAAAAAAEdQ/7pJNRlPTQfU0T8RIR-2McDUaPNX8JrjrACLcBGAs/s1600/figment.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="550" data-original-width="550" height="320" src="https://2.bp.blogspot.com/-j1zhiwYsG20/Wz7LmF0-rYI/AAAAAAAAEdQ/7pJNRlPTQfU0T8RIR-2McDUaPNX8JrjrACLcBGAs/s320/figment.jpg" width="320" /></a></div>
<br />
<br />
General Electric once owned NBC/Universal (which is now a Comcast property). Universal Studios produced the "Despicable Me" movies, starring the Minions. Thus, I propose the name <i>"Minion Healthcare"</i> for GE's new little prodigy. I'll take my fee in small bills, please.<br />
<br />
The various articles about the new lil' baby GE imply that the rationale for the birth was similar to that of <a href="https://www.ft.com/content/57ffd408-d521-11e7-a303-9060cb1e5f44">Siemens</a> (and of Toshiba selling off its healthcare lines to Canon): Cash, or lack thereof. From <a href="https://www.auntminnie.com/index.aspx?sec=sup&sub=cto&pag=dis&ItemID=121150">AuntMinnie</a>:<br />
<blockquote class="tr_bq">
Despite its storied lineage, GE Healthcare got caught in the downdraft created when its parent company in 2017 announced a massive one-time charge to write off liabilities related to a long-term care insurance business that it has sold off. The cash crunch called into question the wisdom of GE's corporate structure as a large, diversified firm with multiple varied businesses. The cash woes and associated stock slump led to GE being removed from the Dow Jones Industrial Average earlier this month.<br />
<br />
The company began jettisoning smaller units to raise cash, and speculation was that the healthcare division would be one of them. But Flannery's assurance that healthcare was a core business prompted many industry observers to believe that medical would remain within GE's fold.<br />
<br />
Ironically, GE Healthcare has been one of the stronger performers in GE's corporate portfolio. The division posted 2017 revenues of $19.1 billion, up 5% compared with $18.3 billion in 2016. The business also grew its profit by 9% to $3.44 billion last year, compared with $3.16 billion in 2016.</blockquote>
Now, of course, <strike>Minion</strike> GE Healthcare <a href="https://www.itnonline.com/content/ge-announces-plans-separate-ge-healthcare-standalone-company?eid=284777417&bid=2156794">puts a different spin</a> on being spun:<br />
<blockquote class="tr_bq">
Kieran Murphy, president and CEO of GE Healthcare, will continue to lead GE Healthcare as a standalone company, maintaining the GE brand.<br />
<br />
“GE Healthcare’s vision is to drive more individualized, precise and effective patient outcomes. As an independent global healthcare business, we will have greater flexibility to pursue future growth opportunities, react quickly to changes in the industry and invest in innovation. We will build on strong customer demand for integrated precision health solutions and great technology with digital and analytics capabilities as we enter our next chapter,” said Murphy.<br />
<br />
Flannery (GE CEO) added, “GE Healthcare is an industry leader with financial strength, global scale and cutting-edge technology. Our talented Healthcare team will continue delivering precision health solutions, building on our heritage of technology innovation that delivers patient outcomes.”</blockquote>
Whatever that means.<br />
<br />
GE's "storied lineage" is the result of acquisition after acquisition after acquisition:<br />
<blockquote class="tr_bq">
GE's roots date back to the 19th century, when a pair of inventors -- C.F. Samms and J.B. Wantz -- founded the Victor Electric Company in Chicago in 1893. They began making x-ray systems one year after Wilhelm Röntgen's discovery of x-rays in 1895.<br />
<br />
A series of acquisitions and mergers followed over the next 25 years, until in 1920 when Victor Electric was acquired by GE, a manufacturer of x-ray tubes. The company grew rapidly over the coming decades, and after World War II moved its headquarters and manufacturing to the Milwaukee area.<br />
<br />
Additional corporate milestones occurred in 1985 when GE bought Technicare from Johnson & Johnson, acquiring Technicare's large installed base of CT scanners; it bought ultrasound developer Diasonics Vingmed in 1998 and CT manufacturer Imatron in 2001. A major acquisition occurred in 2003 with a $9.5 billion purchase of U.K. life sciences and contrast media company Amersham, a move that brought GE into the pharmaceutical business.<br />
<br />
GE Healthcare also accomplished a number of medical imaging product milestones over the years. The company was one of the first manufacturers of CT scanners, installing its first system in 1976. In the early 1980s, it launched its Signa line of MRI scanners, which went on to become one of the best-known product brands in radiology.</blockquote>
GE Healthcare's <a href="http://www3.gehealthcare.com/en/Products/Categories/Healthcare_IT/Legacy_Products">IT Division</a> in particular has been the recipient of a <i>lot</i> of outside technology:<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://2.bp.blogspot.com/-q3l4JVl-O5o/W0AfsHqyQAI/AAAAAAAAEdw/G8yIrBBBZm8N8MdV4ZjCLL_1YCxc8532wCLcBGAs/s1600/Screen%2BShot%2B2018-07-06%2Bat%2B10.03.30%2BPM.png" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1600" data-original-width="1290" height="640" src="https://2.bp.blogspot.com/-q3l4JVl-O5o/W0AfsHqyQAI/AAAAAAAAEdw/G8yIrBBBZm8N8MdV4ZjCLL_1YCxc8532wCLcBGAs/s640/Screen%2BShot%2B2018-07-06%2Bat%2B10.03.30%2BPM.png" width="516" /></a></div>
<br />
The list of companies assimilated into the GE collective includes Dynamic Imaging, as above, whose IntegradWeb PACS is the basis of the mostly-functional Centricity Universal Viewer, and Scanditronix, the predecessor to GE's PET division. Let's look at how these two product lines have progressed to get some idea of how Minion Healthcare might do in the years to come.<br />
<br />
GE, as above, purchased Dynamic Imaging in 2007, for at least $200 Million (some say much more than that). As a user of the venerable old Centricity versions 2-5, I was thrilled for the possibility of a usable PACS, and DI's IntegradWeb was one of the few competitors to give the old AMICAS PACS a run for its money.<br />
<br />
Alas, GE had tremendous problems in integrating Integrad. The plan was optimistic, and could not be fulfilled. I was told many years ago that the Web DX initiative, integrating PACS-IW, with new streaming engine, to Centricity PACS has yet to fulfill the promise that was told to the market upon the DI acquisition. GE also publicly showed, at tmultiple RSNAs, engineering efforts to integrate AW Server with Centricity PACS and PACS-IW. We tried it for several months as a PET/CT reading solution. The AW port itself worked, more or less, but the integration to PACS was so problematic that we had to abandon the effort. We now use Segami Oasis for this purpose. (I wanted MIM, but that's another story.)<br />
<br />
The current incarnation of Universal Viewer does work adequately, but it took YEARS to get this done. <a href="http://doctordalai.blogspot.com/2008/05/follow-green-brick-road-official-ge.html">PACS-IW</a> was first announced in 2008, but the Universal Viewer, the functional version, was <i>finally</i> delivered to us in 2015. (Even then, there were so many problems we <i>almost</i> rolled it back to Centricity 5.x.) UV is a Frankensteinian stitching together of a number of different technologies that GE had acquired, developed and individually brought to market over the years. This jumbalaya of seven products was touted as the Universal Viewer, a "web-based" viewer with numerous capabilities. The components included:<br />
<br />
<ul>
<li>Centricity PACS (RA1000)</li>
<li>Centricity PACS-IW (The immediate descendant of DI's IntegradWeb)</li>
<li>AW Server</li>
<li><a href="http://www3.gehealthcare.com/en/Products/Categories/Advanced_Visualization/Applications/IDI_MammoWorkstation">IDI</a> Breast Workstation </li>
<li>Web DX Streaming Engine</li>
<li>Centricity Clinical Archive (formerly Centricity Enterprise Archive)</li>
<li>Zero-footprint (ZFP) viewer for image review and mobile access. </li>
</ul>
<div>
<br />
<br />
GE previously re-labeled a Calgary Scientific product for remote use. The newer ZFP viewer was/is different than the Universal Viewer itself (and it is significantly more streamlined, i.e. limited in its functionality). Thus, GE continued down the same path of separate viewers for diagnostic and clinical access as with RA1000 and CentricityWeb. (I consider the latter one of the absolute worst pieces of PACS software ever made, and I once told a GE VP exactly that. He looked as if I had just called his dog ugly.)<br />
<br />
It should be mentioned here that Merge managed a similar feat with its PACS, but did a better job of blending the pieces from the original AMICAS PACS, as well as those from Emageon, Merge, and eMed. And it did so after <strike>firing</strike> being unable to rehire the <a href="https://doctordalai.blogspot.com/2010/03/game-over.html">original PACS programmers</a>, despite my sage advice.<br />
<br />
Where does Minion Healthcare take GE PACS from here? Most of the cool kids, I mean cool PACS, have been bought up by other larGE companies, so there will have to be further innovation from within. I have to wonder if the economics of healthcare IT and such will dictate a reversal of the procurement trends. Might we someday see Minion PACS spun off again, to an EMR vendor perhaps?<br />
<br />
Let's move from software to hardware.<br />
<br />
We could have a very long discussion about scanners of all genres, CT, MRI, Ultrasound, Nuclear, PET, PET/CT, PET/MRI, and so on, but as this article is getting longer and longer, and I'm getting older and older, let's concentrate on PET/CT. I have some experience in this realm.<br />
<br />
GE's PET business descends from Scanditronix's scanner division, <a href="http://www.diagnosticimaging.com/ge/ge-buy-scanditronix-line-giving-credibility-pet">purchased</a> at the beginning of 1997 (for some reason, another source says this purchase occurred in 1986 and a <a href="https://cdn.static-economist.com/news/technology-quarterly/7001805-medical-imaging-positron-emission-tomography-more-expensive-and-complex">third</a> says 1990), along with rights to sell the latter's cyclotrons. <a href="https://www.mddionline.com/siemens-acquire-cti">Siemens</a> had been working with CTI Molecular Imaging of Knoxville, TN since 1987, and purchased it outright in 2005.<br />
<br />
You might recall my very famous (or infamous) row with GE over my 2005 blog-post, which I have just republished after suppressing it for many years:<br />
<br />
<a href="http://doctordalai.blogspot.com/2005/07/theres-more-than-one-way-to-scan-pet.html">http://doctordalai.blogspot.com/2005/07/theres-more-than-one-way-to-scan-pet.html</a><br />
<br />
<br />
To make a long story short, I compared the PET/CT offerings from GE and Siemens, and found GE lacking as they were using the older and less efficient BGO crystals. Siemens used the article in its own sales pitches. GE became concerned that I was calling their machines non-diagnostic (I wasn't) and a big commotion followed. Much of the <a href="https://doctordalai.blogspot.com/2008/04/story-according-to-ge.html">problem</a> stemmed from our internal politics, but the controversy tapped into a yuuuggge pool of resentment aimed at GE, and they may well have lost some sales over the issue. I would far rather they lost sales over their equipment, that I felt at the time was inferior, but no matter. We are all best friends now. Sort of.<br />
<br />
Rather than go through the painful discussion of how PET works, I will refer you to these two excellent reviews of the history of PET:<br />
<br />
<a href="https://www.spiedigitallibrary.org/journals/journal-of-medical-imaging/volume-4/issue-01/011013/History-and-future-technical-innovation-in-positron-emission-tomography/10.1117/1.JMI.4.1.011013.full?SSO=1">History and future technical innovation in positron emission tomography</a><br />
<br />
and<br />
<br />
<a href="http://trace.tennessee.edu/cgi/viewcontent.cgi?article=1106&context=utk_interstp2">PET--The History Behind the Technology</a><br />
<br />
In brief, all you need to know about PET scintillator/detector crystals can be found in this graph:<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiDoG9Lb9JSd_ru3Exf_nhZaM_uPTOM4iFOtmgYV0x6FAvqgMyfQzQOs6S6wtZ7lueuVaUI4wSreMRE3JHGr7pRFyjLso3ED5sVdI9M1kgDJYtTfZpWEq0VdTch9I0lhM5BHNi8/s1600/LSO2.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="368" data-original-width="556" height="263" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiDoG9Lb9JSd_ru3Exf_nhZaM_uPTOM4iFOtmgYV0x6FAvqgMyfQzQOs6S6wtZ7lueuVaUI4wSreMRE3JHGr7pRFyjLso3ED5sVdI9M1kgDJYtTfZpWEq0VdTch9I0lhM5BHNi8/s1600/LSO2.jpg" width="400" /></a></div>
<br />
From the first paper:<br />
<blockquote class="tr_bq">
The widespread adoption of 3-D acquisitions challenged the limits of BGO (bismuth germinate), especially for whole-body imaging of large patients. The response was an ongoing search for a scintillator with better light output, faster rise and decay times, improved energy resolution, and reduced dead-time. . .The higher light output would also improve energy resolution leading to a more efficient rejection of scattered events.<br />
<br />
The search led to the discovery of a new scintillator, lutetium oxyorthosilicate (LSO), that had originally been used for nuclear well logging but was found to have much superior light emission properties to BGO for PET imaging. The first commercial PET scanner incorporating LSO was the (Siemens/CTI) ECAT ACCEL that appeared around 1999. . .While some vendors have used a derivative of LSO that incorporates a small percentage of yttrium (LYSO), Philips Healthcare introduced a PET scanner (Allegro) with GSO as the scintillator. The technical advantages of these new scintillators resulted in better energy resolution leading to finer subdivisions in the detector blocks and lower scatter fractions and improved timing resolution leading to lower random coincidence rates. <i>Overall, the new scintillators yielded considerably higher noise equivalent count rates, especially for whole-body imaging of large patients.</i><br />
<br />
<i>A major advantage of LSO, apart from the higher light output leading to better spatial and energy resolution, is the fast timing that leads to lower detector dead time and, above all, the capability to measure the time difference between the arrivals of the two annihilation photons in the detectors.</i> This ability, termed time-of-flight (TOF), provides positioning information for the annihilation point that is not available without TOF. . .(I)t was not until LSO appeared that TOF made a resurgence with the launch of the Philips Gemini TF (TrueFlight) followed by the Siemens Biograph mCT. </blockquote>
I can vouch for the fact that the mCT has markedly better images than the (very) old GE Discovery with BGO crystals (which it replaced in our shop) and mildly better images than the newer LSO Siemens Biograph 16.<br />
<br />
BUT...the old GE Healthcare started doing some major innovation in PET, advancing its PET/CT offerings and managing to produce a PET/MR as well. I think, well, I <i>hope</i>, it is safe to assume that this will continue under the new regime, although the pockets providing funding will necessarily be more shallow.<br />
<br />
It is harder than it should be to determine which scanners have which components. <a href="https://usa.healthcare.siemens.com/molecular-imaging/pet-ct/biograph-mct-flow/features">Siemens</a> doesn't talk so much about solid state detectors, and <a href="http://www3.gehealthcare.com/en/products/categories/molecular_imaging/pet-ct">GE's</a> literature keeps its crystal composition close to the vest. After getting frustrated, I Googled and Googled until I found an <a href="https://ris.utwente.nl/ws/portalfiles/portal/17720104">article</a> that compared the offerings as of 2017. Here's the pertinent table:<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://2.bp.blogspot.com/-XcJqC3Yx0v8/W0AM-0qWQyI/AAAAAAAAEdc/uc6CKclFEhoDHsy4DJBUUvoirn3rTAP7wCLcBGAs/s1600/PET%2Btable%2B.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="636" data-original-width="992" height="409" src="https://2.bp.blogspot.com/-XcJqC3Yx0v8/W0AM-0qWQyI/AAAAAAAAEdc/uc6CKclFEhoDHsy4DJBUUvoirn3rTAP7wCLcBGAs/s640/PET%2Btable%2B.jpg" width="640" /></a></div>
<br />
Notice in particular that one of the GE's (Discovery IQ) still use BGO crystals, but tries to compensate with more rings of detectors, and that the Siemens mCT Flow uses PMT's (Photomultiplier Tubes) and not the newer solid-state silicon photomultipliers (SiPM's), found in the Discovery MI. Siemens does offer SiPM's in the Optiso UDR detector of their newest scanner, the <a href="https://usa.healthcare.siemens.com/molecular-imaging/pet-ct/biograph-vision#TECHNICAL_DETAILS">Biograph Vision</a>.<br />
<br />
GE spent a lot of time and a LOT of money trying to convince the world that BGO crystals could overcome the laws of physics, and indeed they sold the darn things until recently. But the fact that GE finally <i>got it</i>, that their latest and greatest scanner line features LYSO detectors, their flavor of lutetium crystals, and solid state photodetection (nice description of the Lightburst Digital Detector <a href="http://rsna.gehealthcare.com/-/media/91ceb1d3e40248a9bb9d6e4b733ddff1.pdf">here</a>), tells us that Big GE planned to continue to be a Big player in this space. And I guess we can assume that the next Discovery ME (Minion Edition) will continue to avoid being particularly despicable.<br />
<br />
So...<br />
<br />
As a very minor GE stockholder, I'm awaiting my shares of Minion Healthcare. And IF I ever get the chance to purchase another PET/CT, I promise I'll give the Discovery's a look.<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://3.bp.blogspot.com/-ND7Hw-FHp10/W0Ae9XePeAI/AAAAAAAAEdo/j3H8JlS5ZyEcufvJD3vhwuea13OdrbT5wCLcBGAs/s1600/minion%2Bpet.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="432" data-original-width="735" height="235" src="https://3.bp.blogspot.com/-ND7Hw-FHp10/W0Ae9XePeAI/AAAAAAAAEdo/j3H8JlS5ZyEcufvJD3vhwuea13OdrbT5wCLcBGAs/s400/minion%2Bpet.jpg" width="400" /></a></div>
<br />
<br />
<br />
<br />
<br />
<br />
<br /></div>
Anonymousnoreply@blogger.com0tag:blogger.com,1999:blog-10485390.post-74806080390584193172018-06-02T20:24:00.002-04:002018-06-03T11:53:27.892-04:00The Wedding Speech<div class="separator" style="clear: both; text-align: left;">
<i>Dalai's Note: My daughter "Dolly" got married last week to an incredible guy whom we'll call "Lama". Forgive the awkwardness of these false names in the following piece, but I did want to share my "Father of the Bride" speech with everyone. If you were wondering, this might have something to do with my lack of posting lately...</i></div>
<div class="separator" style="clear: both; text-align: center;">
<br /></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://2.bp.blogspot.com/-pxgfVZzHV2Y/WxP64WiJygI/AAAAAAAAEcA/SLtwReiNm-k9HnwU2p9T1gIn73hXU738wCLcBGAs/s1600/33778491_10215676420880015_5548882293692563456_n.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="320" data-original-width="320" src="https://2.bp.blogspot.com/-pxgfVZzHV2Y/WxP64WiJygI/AAAAAAAAEcA/SLtwReiNm-k9HnwU2p9T1gIn73hXU738wCLcBGAs/s1600/33778491_10215676420880015_5548882293692563456_n.jpg" /></a></div>
<div class="separator" style="clear: both; text-align: center;">
<br /></div>
<div class="separator" style="clear: both; text-align: center;">
<a href="https://4.bp.blogspot.com/-FjB_Pm8FYcc/WxMqKEsxHEI/AAAAAAAAEbk/GxULgf0wEHc1LnuB33moXlZptaKjpu7yQCLcBGAs/s1600/IMG_5747.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1080" data-original-width="1080" height="200" src="https://4.bp.blogspot.com/-FjB_Pm8FYcc/WxMqKEsxHEI/AAAAAAAAEbk/GxULgf0wEHc1LnuB33moXlZptaKjpu7yQCLcBGAs/s200/IMG_5747.JPG" width="200" /></a><a href="https://3.bp.blogspot.com/-_YVwgIzyTI0/WxMqUsZ65ZI/AAAAAAAAEbo/vvQFP7Dcsb0pMMgOfN8ed9TF0OnkGcqEQCLcBGAs/s1600/IMG_5692.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="1600" data-original-width="1200" height="200" src="https://3.bp.blogspot.com/-_YVwgIzyTI0/WxMqUsZ65ZI/AAAAAAAAEbo/vvQFP7Dcsb0pMMgOfN8ed9TF0OnkGcqEQCLcBGAs/s200/IMG_5692.JPG" width="150" /></a></div>
<br />
<br />
<div class="separator" style="clear: both; text-align: center;">
<a href="https://1.bp.blogspot.com/-tp8JW9Bo68w/WxMqjMMM4_I/AAAAAAAAEbw/e9OERTJIMYItDlzM-6gVDI-rCYzOtMw9ACLcBGAs/s1600/IMG_5754.JPG" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" data-original-height="960" data-original-width="720" height="200" src="https://1.bp.blogspot.com/-tp8JW9Bo68w/WxMqjMMM4_I/AAAAAAAAEbw/e9OERTJIMYItDlzM-6gVDI-rCYzOtMw9ACLcBGAs/s200/IMG_5754.JPG" width="150" /></a></div>
<br />
<br />
If I could have your attention for just a few moments…<br />
<br />
I want to welcome all of you, our good friends, old and new, and family, old and new, to this celebration for Dolly and Lama! We are thrilled to have you here on this wonderful occasion! I can’t begin to tell you what it means to all of us that you have joined us here in the Rainy North! It’s nice to see that we have about as many doctors as lawyers! I promise to try hard not to make this sound like a closing argument, but maybe more short and sweet, like my Radiology reports: Normal, but clinical correlation required!<br />
<br />
I really want to thank everyone who worked so hard to make this amazing evening possible. First of all, thank you Lama for asking Dolly to marry you, and thank you, Dolly, for agreeing! Obviously, there are quite a few moving pieces to an occasion like this, and Mrs. Dalai and Dolly, with help from our wedding planner, have done a great job of pulling it all together. We might not live up to the standards of that British wedding last week, you know, the one with Harry and Meghan, but I promise we’re going to have an equally good time. <br />
<br />
A marriage unites two people, but it also unites two families. I think Mrs. Dalai and Dalai, Jr., and I are almost as happy as Dolly is about her new husband (I’ve got to get used to saying that!) and her new extended family. We, of course, were not part of the selection process, but I hope we would have done as well! Back in the old days, such decisions were made on the basis of who had the largest tracts of land...we’ve come a long way since then!<br />
<br />
We knew Lama was a special guy from the moment we met him. In fact, on that first meeting, Dolly had been burning the candle at both ends and in the middle, for something new and different, (I think she had been on call the night before) and she managed to fall asleep in her chair over drinks. Of course, it doesn’t take too many drinks to knock her out anyway, but I’m sure Lama knows that by now. So, the three of us ignored her, and talked for several more hours, and we had a great time! That Dolly was relaxed enough around Lama to doze off and leave us to interrogate--I mean talk with him, well, that spoke volumes. By the way, Lama, you passed the interrogation with flying colors.<br />
<br />
A couple should complement each other, and Dolly and Lama certainly do. Both of them are multi-faceted, and they each bring a huge list of talents and interests to the relationship. Dolly and Lama bike, sail and ski together and have introduced to each other to many more activities. Here’s one you might not know about her, Lama: Dolly as a child liked to roller-blade, but she had trouble with stopping when skating down the hill of our driveway, so she usually ended up diving into the bushes at the end of the run. Hopefully she doesn’t do that on the ski slopes! <br />
<br />
While Dolly and Lama do have many common interests, they differ in many ways, like their chosen professions. The combination of a physician and an engineer is a bit unusual. I wear both hats, so I understand to some degree the traits and characteristics that have to coexist. Lama, as an engineer, has demonstrated an analytic approach to things, as well as common sense, at every turn, at least since we’ve had the pleasure of knowing him. Dolly, on the other hand, is an example of why we should be careful about what we wish for. Before Dolly was born, Mrs. Dalai prayed for Dolly to have her nose and my brains. Unfortunately, Mrs. Dalai forgot about my lack of common sense when she made that wish! I’m proud to say that Dolly is a fabulous physician, and has strong and caring instincts when it comes to her patients, but as for common sense, well.... Lama, it will be nice to finally have someone in the family who really does have that very uncommon quality. And good luck, by the way. <br />
<br />
This wouldn’t be a proper Father of the Bride speech without me revealing an embarrassing Dolly story, so I’ll use my favorite to illustrate the common sense thing. Dolly, was named after her grandmother and her great-grandfather, but she has been known by a dozen nicknames over the years: Pookie, Big D, Spark Plug, Artzy Dolly, Sissy (courtesy of Dalai, Jr.) and probably some camp names we don’t know about. And when her mom and I needed to talk about her when she was in earshot, we referred to some little girl named Yllod, Dolly spelled backwards. I’m not sure when she caught on to that one, or if she <i>ever</i> did! Yes, Dolly, that was <i>you</i> we were talking about!<br />
<br />
At the end of her Senior year of High School, she was out and about with her friends, on her way to help with the Senior Prank. This was to be nothing really bad, just filling the halls of her school with balloons. But the police were quite vigilant that night, and while no one was arrested, Dolly did get to have a nice little chat with one of the officers. Now, here’s the punch line: When they asked her name, Dolly, not using whatever common sense she was graced with, quite helpfully answered, “Do you want my real name or the name I go by?” Hopefully we have that problem solved as of tonight. You may know Dolly wasn’t sure what name to use after getting married. Since she has publications in the medical literature, her first thought was to still be “Dr. Dolly Dalai”. But ultimately, she decided to take Lama's name, and so she is now Dr. Dolly Lama. That has a nice ring to it, doesn’t it? <br />
<br />
Along with the new name will come a new dimension in Dolly and Lama's relationship. Those who know me well are quite aware of my warped sense of humor, so forgive me when I declare that it goes without saying, or at least it should, that the marriage is much more important than the wedding. But the wedding is pretty important, too, and seeing the happiness in Dolly and Lama's eyes tonight is certainly the crowning joy of parenthood. <br />
<br />
And so I lift my glass and ask you all to join me in wishing Dolly and Lama a lifetime of happiness and laughter, of joy and harmony. Listen carefully to each other, don’t take yourselves too seriously, but do take each other seriously. May you cherish each other, treasure your time together, and may the excitement of this evening continue throughout your lives together.<br />
<br />
And with that I’ll say, Cheers!!! L’Chayim!Anonymousnoreply@blogger.com0