ARTWORK:

TITLE: Prometheus attacked by an eagle
ARTIST: (attributed to) Rene-Michel Slodtz
MEDIUM: Red chalk on paper
LOCATION: Baillieu Library Print Collection, University of Melbourne, Australia
TIME: c. 1750
DIMENSIONS: 31.9 x 53.3 CM

In my last blog I was sharing my thoughts after a visit to a Radiology department in a busy NHS hospital in London. My observation was that, in the age where information has become the most valuable commodity for clinical practice, our Radiologists have become the information Midas.  Like Midas–the mythical king who was granted his thoughtless wish that everything he touched turned into gold, only to discover that he could no longer eat or drink. Similarly, because of the easy electronic access to medical imaging, our modern Radiologists have found that nearly everything they touch turns into digital information to be downloaded, uploaded, archived, VNAed, analysed, reanalysed and rendered. And to amplify this problem, they are under extreme pressure to consume all this information wealth as fast as it is humanly possible. But what is this wealth really worth? In today’s everyday clinical practice, most doctors realise repeatedly that information is only valuable as it is useful.  Is it the case also for Radiology when it comes to Medical Imaging? I am not sure.

In my opinion, it is ironic that Medical Imaging has become a lot cheaper-cheaper to produce, cheaper to manipulate, cheaper to disseminate. One of our customers, a group of family practitioners in Georgia, USA, bought 3 years ago a refurbished 16-slice CT scanner for next to nothing. Of course they used our SaaS 3dnet platform, as the cost model is utility based, and it lets them adjust the costs based on the workload. For years now they have performed imaging procedures (and a lot of them) with almost no Capital overlay and very controlled costs. Yet another example, closer to home, is my brother in law, an orthopaedic surgeon.  He always carries with him a portable ultrasound device, and he has 2 more of them in his office. I estimated recently that every week he produces around 75 scans. Consequently, virtually any doctor can easily become an information hub for medical imaging. Interestingly, the same statement is also valid for patients (but I hope this is the subject of another blog, so let’s forget about it for now). In Medical Imaging, we are now entering the era of big data and the prospect of living with severe clinical information obesity, unless we invent an efficient diet.

Perhaps another observation is that too many medical experts and too much medical information spoil the clarity, dramatically impacts the quality of clinical outcomes, and puts Radiology at a brinkmanship position. In our era of limitless medical data, there is always the opportunity for some doctor, or researcher to crunch more numbers, produce a few more derived images, spin them a bit, and prove the opposite. We, as a company, provide them with the tools to do that. However with the widening pool of elaborate studies and arguments on every side of every question, more expert knowledge has, paradoxically, led to less clarity.

But this information obesity anathema is not only in medicine and medical imaging, it is everywhere around us; just as fat has replace starvation as this nation’s number one dietary concern, information overload has replaced information scarcity as an important emotional, social, and political problem. Every time I open my browser I get overwhelmed and confused with the plethora of information instantly available to me. I feel under pressure to review and understand it, and I feel increasingly frustrated if I don’t. I am sure you feel the same. My dear reader, even this blog contributes to the information obesity you have to suffer. It appears that the real problem for future technologies in medicine and medical imaging does not appear to be the production of information or the transmission of it. Almost everyone and everything can add information. The difficult question is how to reduce it or even better, filter it. How do we go on an information diet.

The whole debate reminds me of my favourite and greatest story of knowledge acquisition and regret; that of the mythical Greek God Prometheus as told by Aeschylus. Prometheus’ punishment for stealing fire and passing it down to human beings was to be chained naked to a pillar where each day a vulture tore out his liver. The liver was divinely replenished each night, and the vulture would return to eat it out again the following day. In the dialogue Protagoras, Plato puts the story in more contemporary perspective. It wasn’t the fire, but it was the techne–the knowledge of how to make things, or the value of information.

If Prometheus was the prophet, then Johannes Gunteberg was the Messiah of making knowledge public domain. And then somebody in the 80s came with the DICOM idea, the absolute Messiah in Medical Imaging. Today, six centuries after Gunteberg, and 30 years after DICOM became accepted by all, computers and the internet have helped Medical Imaging to move faster and become more plentiful. Doctors everywhere can benefit from this change.  Medical Imaging and the associated information, once cherished like caviar, is now plentiful and taken for granted like potatoes.

However, increasingly we can observe the dramatic postscript to this Medical Imaging information highway; it is the nightmarish prophesies of William Gibson, the man who first coined the word, and even the very concept of, ‘cyberspace’ in his novel Neuromancer. In his novels, he describes a future destroyed by information excess-a disease called Nerve Attenuation Syndrome.

So here it goes. My diagnosis after my visit to our customer is that modern Radiologists suffer from the Nerve Attenuation Syndrome mainly caused by severe information obesity.

Is there a cure for it?

I was visiting one of our customers recently. I admit that this is a favorite pastime of mine.

When we started this company, I was the first salesperson, product manager and marketer, all at the same time, and for years I had been around customers constantly. I have enjoyed that tremendously. However, as Biotronics3D is growing, I find myself increasingly distant from our customers in my day-to-day activities. I do not like that at all. When managing a rapidly growing technology company, it is easy to focus on improving products, systems, operations etc. Sometimes you act as you ignore why and who you’re improving these things for. And answers to those questions are only can be found “out there”, where our customers work, in hospitals and imaging clinics, and definitely not within the walls of the Biotronics3D office, were I work.

Seeking this unfiltered and candid feedback, I stepped through the doors of the fore mentioned customer. And once more there were very important lessons to be learnt. I was very surprised and overwhelmed with the vast amount of work our customers had to do during their day. All the information they needed to understand before they take any action in a very busy, sometime rather chaotic environment. A heap of hundreds of radiology examinations to be interpreted and the heap looked like increasing constantly and not going down. 5 minutes for interpreting a CT study which I would consider a minimum before my visit, I realized that it was a luxury. They were under immense pressure to do more, much more, spending less time, which was once more a big surprise for me. Most of them were at a crisis and breaking point.

But how can the quality of the clinical outcome can be protected when you are asked to operate in such an environment, were meeting targets and increasing throughput is the name of the game? How can you target clinical excellence? Moreover, has our 3dnetmedical.com technical innovation, something that we are so immensely proud off, created this problem for them? Have we given them the tools they needed to get greater access to information only for them to discover there is too much of it? Are we the catalyst that multiplied their problem?

As it happens, I am reading these days an excellent book called “Descartes, Spinoza, Leibniz: the Concept of Substance in 17^th Century Metaphysics” by Woolhouse, a retired Prof. of Philosophy from the University of York, UK. My visit to our customer reminded me of what I was reading the night before.

Prof. Woolhouse in his book revisits one of the great philosophical battles of all time between seventeenth-century philosophers Rene Descartes and Baruch Spinoza. The debate centered on how people perceive, and at what precise juncture a person decides whether to accept or reject a proposition. Put simply, Descartes suggested that first we comprehend a notion, and then we either accept or reject. In contrast, Spinoza suggested that we first simultaneously comprehend and accept a notion, and only afterward, if we have time, are we able to reject it. Thus Spinoza implies that the rejection of a notion is a secondary psychological act. Prof. Woolhouse argues that intensive psychological testing has proven Spinoza to be correct.

Hold on, let’s think about it for a minute. It seems that my dear Professor’s finding is of critical importance in the context of accurate clinical diagnosis and medical imaging, because under conditions of cognitive overload, Radiologists rarely have the time or the focus to go back and question their initial diagnosis. Mistakes thus are inevitable. Thinking deeply cannot be done when they are (over)loaded. The implications of this for the medical community are extraordinary. Radiologists are almost certain to be increasingly more vulnerable to data solicitation that potentially can lead to making the wrong decisions.

Should our Radiologists celebrate when the next generation CT scanner able of producing few thousand of images per scan arrives in their hospital, or should they seek a different discipline? I am not sure.

If Descartes was living today he could claim that our technology, 3Dnet, not only reduces the amount of time it takes to do any one medical task but also leads to the expansion of tasks that healthgivers are expected to do safely, with a given working day. And assuming he had a different dress sense, I would even had given him an offer to join us in our Sales Department. Actually I saw that “expansion of tasks” phenomenon in action during my visit and it was an eye opener. This is what happens to people when they get computers, faxes, mobile phones and other new technologies. In essence, computers are our modern taskmasters, constantly picking up the pace. When humans can’t keep up in certain tasks, computers simply replace people altogether. If you don’t have the right skills, computers and technology may be your enemy.

I was talking to my ex-wife about that, a brilliant Research Psychologist, and she had some very interesting insights to volunteer for the problem of the intense information overload that our Radiologist have to cope with in their everyday work. She said that recent psychological research in the clinical profession reveals a wide variety of effects from information and stimulus overload:

1. Overconfidence: as Radiologists are given more clinical information to digest, confidence in their judgment increased, but accuracy did not.
2. Decreased benevolence: a Doctor’s response to someone needing assistant decreases in likelihood as his environment increases its input bombardment.
3. Impaired judgment: As clinical information load increases, integrated decision making first increases, reaches an optimum, and then decreases. The old law of diminishing returns applies.
4. Frustration: Background noise in the form of unwanted clinical information lowers frustration tolerance and cognitive complexity.
5. Confusion: Radiologists are simply unable to effectively and efficiently process the information.

What is the solution then? Moreover, is there one? Do we switch off our computers and go back to the good old days of film? Do we pretend that this heap of data on our desk does not exist? Nothing is perfect. The good old days definitely were not. The future won’t be. And certainly there is no such thing as technological innovation without tradeoffs. It is not only the luddites that find that hard to accept. The inevitable question thus is how do we negotiate the tradeoffs of the innovation and evolution in Medical Imaging?

Please allow me to list some thoughts in my next blog.