Excerpt originally posted at AlwaysOn
OK, nothing in that one, let’s keep going.” Dr. Solon Finkelstein was
cranking through these at a pretty good clip. About a minute each.
The light box seemed like something out of the 1970’s. Films were clipped in two rows to some white flexible plastic. Dr. Finkelstein would hit a button and a motor would whir and the films would move to the left, wound onto some spool buried in the machine and a new set of films would roll into view.
“I’ve been doing these since 1967, you know. Not much has changed. Oh, the film is better, but the rest of this…” he waved his hands in front of the contraption.
To his right were color-coded files, the same ones I remember seeing in my pediatrician’s office in, well, 1967. Dr. Finkelstein wore a head mounted magnifier, one that you might see a jeweler wear. He would occasionally lean forward to look closely at the films.
“Some like to hold up a magnifying glass but I like to keep my hands free for the papers and the dictation machine,” he said.
After peering at the films, Dr. Finkelstein would push a button and a view of the films would come up on two small monitors that seemed to be gerry-rigged to the light box. He would then read a barcode on the patient’s records - how ‘80’s - and push a button on a phone and talk into a microphone “Patient Smith, negative, 12 month review, Solon Finkelstein.” Two marks with a pen on a sheet of paper and then “OK, let’s go onto the next one.”
I stifled a yawn. I had somehow neglected to tell my wife I was going to be checking out women’s breasts all morning. I think she’d understand. Staring at mammograms with a 70 year old radiologist is probably not considered, er, titillating.
“OK, here’s something.” I shot up in my seat. Finally, some action.
“Looks like some calcification there, no problem.” Oh. “But what’s this?” He took out a red grease pen and circled what he was looking at.
“Granular tissue, perhaps?” I was glad he was thinking out loud so I could understand what was going on, but I remembered that most doctors tend to think and talk simultaneously. It can be unnerving.
“Let’s see what R2 thinks.” He pushed a button those two tiny monitors lit up. They had the same identical views as the films we were looking at, except there were a few black triangles and asterisks on them as well.
“Uh
huh, R2 sees it too. These triangles are just calcifications, but that
asterisk means it might be a mass. Yup, we agree. Usually do. It might
be a mass, let’s check last years film. Might be something. No, this is
probably no problem. See, it’s the same size, it hasn’t grown. No
problem. Good.”
He picked up the microphone, reached over and pushed the button on the
phone as I had seen a dozen times already, “Patient Jones, benign.”
Pause. “Let’s schedule a six month follow up. Solon Finkelstein. Next.”
That took about 2 minutes.
He was slipping.
“The Bio-Rad classification book is over there, that big thick one, if you want to go through the government regulations,” he said with a smile.
“No, thank you.” I said.
“The government insists that if there is something, but less than 25% what I consider granular tissue, I have to call it ‘Probably Benign’ and follow up in three to 12 months. But who wants to get a report that says Probably Benign and worry all that time? It’s a judgment call but its often better to say benign and follow up in six months.”
The next set of films rolled into view.
“Oh goodness.” Dr. Finkelstein sat back a bit. I noticed that the image on film was twice the size of the others and seem to run off the page. “Well, the extra ones must be here somewhere, usually they are in the file, oh, here it is. Yeah, sometimes we require an extra shot to facilitate the, er,…” I got it. Pamela Anderson.
“I feel like going home and getting my catchers mitt,” I said to Dr. Finkelstein. I thought he would like the Woody Allen line. Instead, I got a disapproving glance. OK, no more jokes.
“Some vascular calcifications, no problem. Looks clean. OK…” The two small monitors lit up. “R2 seems to agree, just calcifications, no masses.”
I invested this Saturday morning at the Palo Alto Medical Foundation to learn what radiologists actually do for a living. I figured I would discover some radical change in digitizing film and pulling them up on a LCD monitor and electronic medical records, but something else entirely seemed to be going on here and it confused the heck out of me.
“Doc, I promised I wouldn’t get in the way, but you keep referring to what R2 thinks. Is that another radiologist? Radiologist 2?”I asked.
“Sort of. Here, I’ve had enough of this for now. Let’s take a walk, I’ll show you around and maybe you’ll get an idea of how this works now.”
He took off the magnifying headset, scattered the papers around and I quickly followed him out the door. Doctors both talk to themselves AND walk with quick pace.
“OK, this is the mammography machine. You can figure out for yourself what goes where. We take a top down and a side to side view, four films in all. A tech brings the films over here to this Kodak machine where they are developed,” I could hear Beavis and Butthead whispering in my ear ‘did he say developed, heh, heh.’
“It takes all of 90 seconds and the films end up in this bin. The tech just moves them over here to the R2 box and loads them in.”
“This is R2?” I asked. “It looks like a copying machine.” Besides being purple, the R2 was a pretty non-descript box. Films were fed in on the top and ejected to a bin at the bottom. An LCD display on top had a few bars moving across the screen, to show progress. But progress of what?
“The R2 scans all our mammogram films. I think it takes 30 seconds per image. I look at the original films and then I can then pull up what R2 thinks on those monitors. We used to do double blind - two radiologists reading every mammogram, that’s the law. Now, it’s just one and R2. They call it computer aided detection, and we can do away with the extra human reading. To me, it’s a pretty good backup,” he said with a certain satisfaction.
This was new on me – and definitely something that could scale. A doc in a box.
“We do a lot of mammograms here. This is a slow morning and I’ll probably go through 40 of them. They’ve been underpaying for mammograms for years.”
“They?” I asked.
“Oh, Medicare, insurance,” he said.
“Got it.”
“It gets kind of expensive to have two of us read films, so one plus R2 works. Maybe even better, not sure. Plus we get reimbursements - $29 I think.”
“This is pretty new?” I asked.
“We got one of the first ones. R2 is down in Sunnyvale or Mountain View or something.”
Figures, I’ve probably driven by them a million times, imagined D2 across the street and figured it was a robotics company.
“Most mammograms are negative. I think something like one half of one percent show actual cancer. We find that younger docs,” he looked at me like I represented one of those young turks, “recall something like 10% of patients, for biopsies or MRI or something else. That’s a pretty high false positive rate. Us old guys are at around a 4% recall rate. Hey, I’ve done 250,000 of these over my career and never been sued.”
This is about the last guy I would imagine embracing new technology, but here he was asking what R2 might think. Amazing. Then again, his job looked pretty dull to me. Negative, negative, negative. One out of 25 recalled. One out of 250 is actual cancer. That’s a lot of negatives. It’s like counting cars on the highway, you are inevitably going to miss a few.”
Bells started going off. I think I just had a Eureka moment. It doesn’t happen very often, but I’ve learned to recognize the sensation. Here is a piece of technology that not only augments doctors, but potentially replaces them.
I couldn’t help but ask, “So, do you see a day when R2 would look at films first and then alert you to look only at the ones it flags.”
I thought he would roll his eyes and harrumph or something, but cool as a cucumber Dr. Finkelstein answered, “I don’t think so. Technicians do that already - flag something they see on film, put a mark on it. But the liability is so great, I don’t see your scenario happening. I’ve never been sued, but you need someone to blame.” He paused and pondered, “Except maybe in the military, you can get away with anything in the military.”
There was another long pause. I think I just found my first use of technology, real bits and bytes and processors and gigabyte drives that not only get cheaper every year, but are changing healthcare for the better. Not like those discredited scanners.
“This is a very efficient process and mindset. It’s all about the experience curve.”
Interesting choice of words.
I pulled an "all nighter" reading it and overall, enjoyed it. You articulate what is becoming obvious to those of us in the trenches of medicine. My only beef is with your reference to the poor shlemiel of an internist as "Dr. Greedy".
Mr. Kessler- tut tut. This from a man of your stature in an industry where the going rate is 20% of profits and 2% of AUM. That's a real knee slapper. Oh well, I suppose when Dr. Greedy gets rebooted, he can always start up a hedge fund.
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