The Abscopal Effect

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.

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: "You read a scan...") 

He had me look first at a PET/CT from earlier in the year on this elderly patient:

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. 

OK...now, here is the most recent study:

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.)

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..."

What in the world is the "Abscopal Effect"?

From the Wikipedia:

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.”

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.

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.

Visually (also from the Wiki):

"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.'

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. 

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? 

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...

A Cold-Call Email From A Headhunter

I HATE SPAM. HATE IT. With a passion. Almost as much as I hate robocalling telemarketers. I REALLY hate them. 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.

But back to email SPAM.

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 are 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.

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.

My latest bemusement stems from the following communication. The company involved will remain nameless, unless someone gives me a reason to mention it...

Subject: Re: Primary Care Providers - Can you recommend a colleague?

If you aren't interested, please unsubscribe rather than marking as junk.

Good Afternoon Dr. Dalai,

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:

(My Hometown)
Mon-Fri 8:30a – 5p
No afterhours, no weekend call
20-30 patients per day
Treating substance withdrawal

Please let me know if you have any interest or know of a colleague to refer. I look forward to hearing from you!

Thanks,

RB - Primary Care Recruiting Specialist

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 didn't. This response went out immediately:

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.

This got the attention of someone higher up in the company food-chain:

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

Respectfully, RM, USMC ret.

Vice President of Recruiting and Gov’t Ops.

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?

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:

Thank you. Please let me know the source of my email address so I can put a stop to this sort of thing.

The response came quickly:

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.

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.

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:

I would say it took incredible gall for you to even ask that question.

Please provide the name of the manager/owner of your company. I need to have a little talk with them, it seems.

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:

Dr. Dalai,

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.

Respectfully, RM, USMC ret.
Vice President of Recruiting and Gov’t Ops.

No Impudence? Heck yes, there was Impudence! Keep me in the data base but never send me emails? Right.

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.

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.

Until the next outrage...

"Despicable" GE Spins Off...Minion Healthcare?

I couldn't let an occasion as momentous as General Electric 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.

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 relationship with Disney...

...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 GE  once touted a "Healthymagination Initiative" worthy of Figment himself.)

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 "Minion Healthcare" for GE's new little prodigy. I'll take my fee in small bills, please.

The various articles about the new lil' baby GE imply that the rationale for the birth was similar to that of Siemens (and of Toshiba selling off its healthcare lines to Canon): Cash, or lack thereof. From AuntMinnie:

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.

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.

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.

Now, of course, Minion GE Healthcare puts a different spin on being spun:

Kieran Murphy, president and CEO of GE Healthcare, will continue to lead GE Healthcare as a standalone company, maintaining the GE brand.

“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.

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.”

Whatever that means.

GE's "storied lineage" is the result of acquisition after acquisition after acquisition:

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.

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.

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.

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.

GE Healthcare's IT Division in particular has been the recipient of a lot of outside technology:

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.

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.

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.)

The current incarnation of Universal Viewer does work adequately, but it took YEARS to get this done. PACS-IW was first announced in 2008, but the Universal Viewer, the functional version, was finally delivered to us in 2015. (Even then, there were so many problems we almost 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:

• Centricity PACS (RA1000)
• Centricity PACS-IW (The immediate descendant of DI's IntegradWeb)
• AW Server
• IDI Breast Workstation 
• Web DX Streaming Engine
• Centricity Clinical Archive (formerly Centricity Enterprise Archive)
• Zero-footprint (ZFP) viewer for image review and mobile access. 

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.)

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 firing being unable to rehire the original PACS programmers, despite my sage advice.

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?

Let's move from software to hardware.

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.

GE's PET business descends from Scanditronix's scanner division, purchased at the beginning of 1997 (for some reason, another source says this purchase occurred in 1986 and a third says 1990), along with rights to sell the latter's cyclotrons. Siemens had been working with CTI Molecular Imaging of Knoxville, TN since 1987, and purchased it outright in 2005.

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:

http://doctordalai.blogspot.com/2005/07/theres-more-than-one-way-to-scan-pet.html


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 problem 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.

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:

History and future technical innovation in positron emission tomography

and

PET--The History Behind the Technology

In brief, all you need to know about PET scintillator/detector crystals can be found in this graph:

From the first paper:

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.

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. Overall, the new scintillators yielded considerably higher noise equivalent count rates, especially for whole-body imaging of large patients.

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. 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.

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.

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 hope, it is safe to assume that this will continue under the new regime, although the pockets providing funding will necessarily be more shallow.

It is harder than it should be to determine which scanners have which components. Siemens doesn't talk so much about solid state detectors, and GE's literature keeps its crystal composition close to the vest. After getting frustrated, I Googled and Googled until I found an article that compared the offerings as of 2017. Here's the pertinent table:

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 Biograph Vision.

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 got it, 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 here), 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.

So...

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.

The Wedding Speech

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...

If I could have your attention for just a few moments…

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!

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.

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!

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.

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!

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.

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 ever did! Yes, Dolly, that was you we were talking about!

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?

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.

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.

And with that I’ll say, Cheers!!! L’Chayim!

Driving "Miss Taxi"

As my second trip to Ghana winds down, I think of what I've seen and accomplished. The people I've met, the places I've visited. The mark I've left on this wonderful nation, and that it's left on me. One returns from a trip like this a better person, and that growth is enhanced by those who touch your life during the brief sojourn away from the known.

I have literally met royalty this trip (long story, won't talk about it for privacy reasons.) I've worked and played with some very fine physicians, IT people (yes they are!), technologists, and and so forth. Neither an abundance nor a lack of resources can dictate the someone's quality (or lack thereof). Suffice it to say, there are good, kind, capable, and amazing people anywhere and everywhere. You just have to find them.

I'm going to tell you about the most amazing person in Ghana, perhaps in Africa, and maybe beyond that. Her name is Esenam Nyador, but she is known throughout Ghana as "Miss Taxi". And she is KNOWN throughout Ghana. Everywhere we went, she was recognized and greeted as the celebrity she truly is.

My fellow volunteer discovered Esenam in the process of figuring out what to do over the weekends, when there is little activity at the hospitals. Any Google search involving "Ghana" and "guide" will yield listing after listing mentioning "Miss Taxi". And so, we had a tour like I've not experienced anywhere in the world, planned, executed, and delivered by someone who is very clearly proud of her nation. Her love for Ghana shines through at every point, and it is very, very infectious.

I could give you a travelogue, and drone on with descriptions of stop after stop. But I'm not going to do that this time. I'm not even going to put up more pictures. You need to come here and see this place for yourself, and you need to have Esenam show it to you. Trust me. I'm a doctor.

So what's the big deal with "Miss Taxi" you ask? It's all there in her nickname. Miss. Because Esenam has almost single-handedly broken into a formerly (and still, to a considerable degree) all-male field.

The odds were truly against her. Esenam was a single mother of two boys when she decided she was not going to let the world keep her down. Scraping by to make ends meet, she went to college, getting her first degree (Social Work major, Psychology minor...her SECOND degree is a Master's in Family Resource Management) from the beautiful University of Ghana. (I know it's beautiful because Esenam drove us through the campus, and we were able to see it through her eyes.) Having a rather strong entrepreneurial spirit, not to mention just a touch of rebelliousness and maybe just a bit of feminism, she chose the taxi business "because this is is a very non-traditional thing to do for a woman in Ghana, and I think of my decision as a gender statement. I didn’t mind stepping on a few toes to change the status quo."

In the United States, we might shrug and wonder why this is a problem, but in Ghana, it's a problem. A BIG problem. The male Taxi Unions would not let her participate in the business. Until, that is, she offered to take the riders they wouldn't transport. And from there, she built a thriving business.

People still stare, four years into this social experiment, if you will, at the "lady taxi driver". While there are a few more, this is still a male-dominated business. But there are clients, perhaps mainly female, who feel safer with a female driver. And many of those women have husbands. See how it goes?

Esenam has been featured on Ghanaian television, and has received worldwide praise and notoriety. She has TWO big ongoing projects, one that trains women to drive buses, and the other, trucks.  In fact, she's just back from Germany, where she received a rather important award. I'll let her tell you about that and her two ongoing projects:

The project that I work on is known as Women Moving The City Project. It seeks to training 60 women to drive intra-city commuter buses in Accra. The training is gradually grinding to its end and our ladies are awaiting the official agency to test them and grant them driving licences. The project is been funded largely by GIZ Ghana, Scania West Africa and West Africa Transport Academy. I actually started out as a volunteer for the project, right from the project campaign design stage as the ambassador. Months into the project, GIZ Ghana hired me as the Gender Consultant on contract and they are extending my contract till August to cater for the second project. It humbling to know that my volunteerism to help empower fellow women has not gone unnoticed! The project won a third position prize in the GIZ Global Gender Projects award in Germany on the 9th of March this year.

The second project has just been rolled out. It's dubed Women Moving Trucks. It's equally funded by the same team. Twenty women are to be trained for a logistics company for ready employment to transport goods on the western corridors of Ghana.

I could go on.

Kids, I'm not a feminist. I'm not a chauvinist. My daughter, Dr. Dolly, says I'm a humanist. If that translates to simply not caring about trivial differences, I'll accept the title. But seriously. I have always had a few innate beliefs, and Number One on my list is that everybody is equal, and should have the opportunities afforded to anyone else. I've just always felt that way. Can't tell you where I got it. Everyone has strength and nobility, and so on, and we need to celebrate that, and we need to let everyone on the planet evolve to their full potential. Keeping someone from doing so because of their gender or skin color or whatever is just plain stupid. I can't drive a truck or a bus, and I wouldn't last 39 seconds driving a car on the streets of Accra. But I have zero problem working with someone who DOES have those capabilities. Female? Why do I care? Get me there safely and comfortably please. Which is exactly what Miss Taxi does. 

Ghana is a poor nation, but its people are the most gracious I've met in a lifetime of world travel. Their hospitality is second only to their generosity. All they want in return is to know that they have pleased you. What they might lack in material wealth, the Ghanaians make up for with their honesty, and humility. And Esenam is the epitome of Ghanian grace.

Come to Ghana, to Accra. And let Miss Taxi show you the sights. You won't be sorry. Unless you ride with someone else!

April's Fool

Good morning. Happy Easter, and Happy Passover, and Happy Whatever to those to whom the first two don't apply.

Having been hard at work in Ghana the past two weeks, and trying to get back onto Eastern Time this weekend, for the first time in the history of DoctorDalai.com, there will not be an April Fool's Day post.

Sorry to disappoint. I know you wait for this with great anticipation every year, but I'm going to have to let you down. In the meantime, try Google's version.

Rest assured, next year's edition will be YUUUUGGGEEE!

Dalai

I Bless The Rains Down In Africa...Again

Some of you might have noticed that I haven't posted for a while. Did you call? Did you write? Did you check to see if i was still alive?

Sorry...just the Jewish mother in me coming out. I'm sure you all knew that the hiatus was justified, and you simply decided that my next missive would be well worth the wait. And I certainly hope to rise to your expectations.

Many things have indeed been happening. Doctor Dolly is getting married in a few months, and you can imagine the turmoil joy that has brought to the Dalai household. In the midst of plans for that amazing(ly expensive) event (JUST KIDDING, DOLLY!!) I received a promotion to the Management team of RAD-AID, which has taken up a great deal of time. Fortunately, this came with a tripling of my salary from my favorite NGO...I went from $0 to $0, but the satisfaction derived from being a part of this is priceless.

And yes, I've been back in Ghana for the past week on another RAD-AID trip to Korle Bu Teaching Hospital in Accra. As I noted upon last year's expedition to Dar es Salaam, Tanzania, you just can't be in Africa without thinking of Toto's song by the same name, and I must again present both the original and a very moving chorale version:

OK, time for business.


I have been delivering lectures to staff, residents, and anyone else we can gather. I managed to hit the ground running in that regard with an introductory talk about Nuclear Medicine to the Internal Medicine Department. Which occurred at 8AM sharp the day after I arrived in Accra (at 8PM but who's counting...) Despite some computer glitches (when connected to the projector, my borrowed laptop tried to go into Picture in Picture mode or something like that), the talk seemed to be well-received and there were many good questions asked.

We were able to meet with some of the radiologists and with Dr. Awo, the Nuclear Medicine physician:

My main duty here at Korle Bu, beyond boring the staff with Nuclear Medicine lectures, is to help pave the way for a RIS to mate with the PACS. There will be many discussions in that regard as we progress, but the principals here are pleased with the way we are approaching this project.

I have been able to travel a bit, seeing Accra last Saturday and going back to Cape Coast Castle and the Kakum Canopy walk on Sunday. I'm not going to post all 300+ pics, but here are a few highlights. I have to note that wherever we went, little children tagged after me, and usually not the ladies. I'm thinking they saw the old white guy with the white beard and figured I was Santa Claus. Ho, Ho Ho! Christmas in March in Ghana! Except it turns out that there is no Santa tradition here. Oh, well....

I've got another week to go, with a trip to Kumasi and a surprise!

I should note that I don't speak even the slightest bit of Twi, the more common of over 70 dialects in this region...I tried last time, and after getting laughed at, I decided to stick to English. It IS the official language of Ghana, after all!

But for now, I bid you Maadwo, a very good evening!

Life REALLY Imitates Art! More on Apple's EMR

To welcome myself back after a two-month absence, I'll brag a bit about my prescience. You'll recall my April Fool's Day mock-up of an Apple EMR:




No, it wasn't real, for those who didn't realize this.

But as with "The Simpsons" predicting an unlikely candidate (some say this isn't true, but go with it),

Apple has finally come around. I alluded to this in a recent post, but it seems to be coming to pass quickly. Here's the latest, from Wired of all places...

IN LATE JANUARY, Apple previewed an iOS feature that would allow consumers to access their electronic health records on their phones. Skeptics said the move was a decade too late given a similar (and failed) effort from Google. Optimists argued that Apple was capable of translating health data into something meaningful for consumers.

But the announcement portends great things for consumers and the app developers seeking to serve them, from our perspectives as the former US chief technology officer under President Obama, and as an early adopter of the Apple service as Rush University Medical Center’s chief information officer. That’s because Apple has committed to an open API for health care records—specifically, the Argonaut Project specification of the HL7 Fast Health Interoperability Resources—so your doctor or hospital can participate with little extra effort.

This move is a game-changer for three reasons: It affirms there is one common path to open up electronic health records data for developers so they can focus on delighting consumers rather than chasing records. It encourages other platform companies to build on that path, rather than pursue proprietary systems. And it ensures that the pace of progress will accelerate as healthcare delivery systems respond to the aggregate demand of potentially millions of iPhone users around the world.

Understanding the promise of this announcement requires a bit of historical context. In the wake of the 2008 economic crisis, President Obama signed into law the Recovery and Reinvestment Act, which included more than $37 billion for investing in the adoption and use of electronic health records by doctors and hospitals. Tucked away in that program was a comparably modest $15 million investment in research and development to bring to life a vision of applications inspired by Apple’s App Store. That R&D funding contributed to the development of the open API standard that Apple now requires of providers wishing to make the feature available to their patients.

Spurred by financial incentives in the Recovery Act, the Affordable Care Act and in 2015, the bipartisan Medicare Access and CHIP Reauthorization Act, providers are implementing health IT systems that are certified to meet certain government requirements.

One such mandate is to allow patients the ability to connect any application of their choice, like Apple Health, to a portion of their records via an API. However, the government left room for the private sector to build consensus on how to achieve this requirement, which resulted in the Argonaut Project specification. Apple's decision to require that open API standard decreases the likelihood that health IT developers will adopt a proprietary system.

Better still, once a provider’s electronic health records system delivers health data in accordance with the standard, that same connection will be available to any app developer offering consumer applications, including those built for the Android ecosystem, or competing to serve the highly anticipated Amazon, JPMorgan Chase, and Berkshire Hathaway employee health joint venture. Imagine if Apple had instead introduced a proprietary system that didn't allow competitors to access data in the same manner from the participating providers.

Naysayers point out the fact that Apple is currently displaying only a sliver of a consumer’s entire electronic health record. That is true, but it's largely on account of the limited information available via the open API standard. As with all standards efforts, the FHIR API will add more content, like scheduling slots and clinical notes, over time. Some of that work will be motivated by proposed federal government voluntary framework to expand the types of data that must be shared over time by certified systems, as noted in this draft approach out for public comment.

Imagine if Apple further opens up Apple Health so it no longer serves as the destination, but a conduit for a patient's longitudinal health record to a growing marketplace of applications that can help guide consumers through decisions to better manage their health.

Thankfully, the consumer data-sharing movement—placing the longitudinal health record in the hands of the patient and the applications they trust—is taking hold, albeit quietly. In just the past few weeks, a number of health systems that were initially slow to turn on the required APIs suddenly found the motivation to meet Apple's requirement.

When we look back a decade from now to render judgment, it will be the impact Apple Health has had in changing the default setting in health information sharing—from closed to open.

Two points. First, I knew there had to be something about Obama Care that wasn't all bad. This is it. Second, don't count Google out.

Still, Apple is the master of usable GUI's, and IF they continue down this path, they will be come a major player in this space.

Told you so.