World Transformations and the Challenges of New Textures in Radiology

The year is 2025, in some city in the interior of São Paulo. Dr. Rafael calmly takes his breakfast - a menu specially prepared by his “chef” & personal assistant ”Alexa, who seeks to improve his health indicators (cholesterol, triglycerides, glucose and others). Your refrigerator is also connected via IoT to your meal plan. While drinking coffee, Alexa it transmits to him by voice the main information cured exactly for him, as well as what will be the personalized learning path through algorithms that day. Since last year, with the full adoption of Teleradiology, he feels less stressed because he was released from having to spend long hours in hospitals and clinics, going to work a maximum of twice a week. At home, or wherever you are, you use technology that renders 3D ultrasound images in augmented reality, with perfect accuracy and in real time. Artificial intelligence (AI) software helps you in diagnostics. One of the advances towards precision medicine that Dr. Rafael has been improving is the radiogenomics allowing you to analyze the correlation between cancer characteristics obtained by imaging and gene expression, with better metrics for more accurate diagnoses; organically, he has been diversifying new skills and seeking knowledge in genetics and population health.

At that very moment, Dr. Rafael is notified that a woman had arrived early at the hospital with chest pain, high D-dimer, history of lupus anticoagulant and DVT in the left femoral vein. Her clinical data had already been compiled and analyzed by cloud AI and the likelihood of the patient having a pulmonary embolism (PE) was considered high. The algorithm itself recommended that computed tomography angiography be performed. It is important to note that it was not the radiologist who requested CT angiography, but the machine learning algorithm based on a mountain of data and documents, which he read and interpreted in an instant and fluid way. The patient underwent the exam and the AI was in fact correct in pointing the PE. The algorithm also analyzed bone structures, the heart and the lung parenchyma, pointing out abnormalities and making clinical and radiological recommendations. The exam (and diagnosis) was then forwarded to Dr. Rafael's bracelet via an app, which analyzes it right after getting up from the table and going towards your home office.

As we imagine this possible future, the question that arises is: what will be the main role of Dr. Rafael and his fellow radiologists going forward?

In 2025, society as a whole already better understands the impact of the coronavirus that hit the world in 2020 from an evolutionary systemic perspective. Looking at the last 5 years - turbulent and recessive due to the pandemic crisis -, it seems obvious our interdependence and interconnectivity. There is a growing human awareness of how the planet really works and that rampant economic growth has culminated in increasing social and environmental losses, which have caused collapses, inequality, poverty, disease, loss of confidence in institutions, and also led to 21st century pandemics , SARS, MERS, AIDS, influenza and coronavirus.

Five years ahead, people are better prepared for “black elephants”Which are those extremely likely and widely anticipated events, but generally ignored, and that people tend to regard them as“black swan”When they happen, as was the case with the COVID-19 pandemic that had been foreseen and that cost millions of lives. With the advancement of AI and Big Data, it is already possible to learn from past pandemics, gathering relevant data and debugging knowledge to create more resilient environments, and better prepare to respond to potential health crises like new pandemics.

Black Elephant (Black Elephant) is a likely and widely anticipated event, generally ignored. Black Swan (Black Swan) is an "extreme" event, which goes far beyond our observations and can be considered an outlier, "a point outside the curve". The Black Jellyfish represents events and phenomena that were not foreseen or imagined (Image courtesy: Day One Futures).

Returning to 2020, we are already beginning to feel these “post-normal times”. We already feel that the notion of velocity has been changing. Everything starts to be digitized and becomes exponential. Acceleration is accelerating! What used to take years can now be accomplished in days, or even seconds. The rate at which the “new” drops the “obsolete” is staggering. An example? The GPU software manufactured by Nvidia in 2015 needed 25 days to train the ResNet-50, an extremely complex algorithm (arguably more complex than most of all image algorithms); in July 2020 the new GPU allowed this learning to take only a few minutes; if that pace continues, in 2025, it will take seconds.

The world is not only moving faster, it is also becoming a “smaller” place. A small event, in a small village, can impact opposite ends of the globe at great speed. Air travel and the constant international movement of goods and services can spread a virus from a village and turn it into a global pandemic in a matter of weeks and days. The transmission of news 24 hours a day almost immediately and social media can turn an insignificant news into a global show in a matter of minutes.

The notion of scale also changes. Global events quickly have an individual and community impact. What happens at the international level affects the lives of people across the planet - financial crisis, pandemics, terrorism, climate change, development of new applications, surveillance and even a shortage of medical equipment. We can no longer ignore what happens in some remote corner of the planet, because the impact of these events is quickly being felt around the world.

Uncertainties, chaos, contradictions and complexity characterize post-normal times. Photograph of the Post Normal Times exhibition at The Museum of Contemporary Art in Antwerp (M HKA).

THE volatility that is characteristic of the VUCA world becomes even more accentuated with the proliferation of simultaneity. Crises are no longer localized - in a particular community and in the lives of individuals - but several of them tend to appear at once! Technological advances have allowed us to clearly map the effects of an economic crisis, a political crisis, which occur simultaneously with a public health crisis. In 2018, the Ebola and MERS epidemics occurred simultaneously. Currently, most scientific discoveries and inventions are made simultaneously by various groups of scientists. A single event can trigger a chain of events that leads to everyone being simultaneous.

Given these post-normal times, how can radiologists prepare?

The main weapon or tool for dealing with uncertain and complex times is the development of the ability to navigate them. And for that, the ability to be in constant learning is fundamental. How do you propose Astro Teller, head of the Google research lab (X Company), the only way to stay stable today is to be on the move all the time. Using the bicycle metaphor: we are in balance when we are pedaling. What was it Teller called "dynamic stability". And that is exactly what one of the most talked about concepts about the skills needed to deal with the future is about: lifelong learning or continuous learning - an important way not only to think about education, but also work in the 21st century. This concept goes far beyond formal education, recognizing that the source of this continuing education is multiple, vast and comes from countless domains.

The graph above shows scientific and technological progress over time (Y axis) and how humanity - individuals and society - adapt to change. Thomas Friedman, in his book Thank You for Being Late, explains this theory, as well as the changes in the curve, which are based on a conversation with Astro Teller. (Courtesy: Embedded Computing Design)

The concept of lifelong learning applies perfectly to the challenges that lie ahead in the area of Radiology so that professionals remain relevant. The dimension of lifewide learning (education that covers all aspects of life) emphasizes the complementarity between formal, non-formal and informal learning. Learning evolves from accumulating knowledge to working on knowledge flows with a transdisciplinary mindset of human-technological collaboration. It is analogous to learning to master a single instrument versus learning to conduct an orchestra.

Dr. Atul Gupta, chief medical officer for Image-Guided Therapy, at Philips, considers that the collaboration is the most important capability that radiologists need to be aware and develop. “Many times, other specialties call us to solve problems that are unique and singular, and that allows me, as an interventionist radiologist, to be creative. If I advance 10 or 15 years, I would not be surprised to see a lack of definition between the specialties, because many of the procedures we do are increasingly overlapping. Who today is a specialist in critical limb ischemia (CLI), or AAA, or venous disease? Many cardiologists, surgeons and interventional radiologists. I think we are starting to see doctors coming together and learning various specialties. I saw vascular surgeons, cardiologists and radiologists joining the CIRSE[…] We also see several specialties coming together. None of us works in a vacuum, so exceeding limits [silos] to serve the patient is extraordinarily important, not only for doctors, but also for the entire industry. Collaboration leads to the best in innovation. ”

With the growth of remote work - as well as Telemedicine and Teleradiology - the ability to collaborate it becomes even more important for doctors to work productively, participatively and collaboratively in virtual teams, generating engagement and trust between their peers or patients.

One of the things that really needs to improve is the quality of diagnostic accuracy, believe Dr. Samir S. Shah, who serves as VP of Clinical Operations for Radiology Partners. “We radiologists are human, we make mistakes. […] So, I believe that AI is a great way to check and measure the work of radiologists. It can be an incredible tool without the stigma of current peer review systems, which do not focus on learning. ”

As an autonomous car “driver” or an airplane pilot using autopilot - in this case AI - it is as if the radiologist knows your route plan (or flight) inside and out, being ready to take on control at any time.

Although radiologists don't know how to build MRI equipment, they do know how the fundamental concept works. The same applies to AI. “We will not know how to make our own algorithm or model, but we have to understand what were the principles that went into it and how it was developed. […] I think it is important for future radiologists to be familiar with many of the concepts that, unfortunately, are not being taught now. […] They don't teach us how an AI system works, or what data science is and so on. ”, alert Dr. Matthew Lungren, director of the Stanford AIMI Center; assistant professor of Pediatric Radiology at Stanford University Medical Center.

In this video, Dr. Nina Kottler, Vice President of Clinical Operations at Radiology Partners, explains how he believes that intelligence will transform radiological practice. (Credit: Applied Radiology)

The problem is that, as believe Dr. Nina Kottler, young radiologists are not being prepared for the future of the profession. Dr. Nina, who is Vice President of Clinical Operations at Radiology Partners, argues that it is necessary to understand the basics of how the algorithms work to be able to speak the language of AI and data and understand potential biases. “The radiologists of the future will need to give guidance and advice based on the knowledge generated from these systems. We also need radiologists who can translate clinical cases for AI developers to ensure that new models that are created add value to our patients and healthcare systems.. ”

In short, radiologists today need targeted machine learning training to understand what can go wrong and identify when something goes wrong.

Radiology is at the forefront of many technological advances in medicine, but radiologists need to adjust their perspectives if they are to remain relevant”. That was the message given by doctor Valerie P. Jackson, president of Radiological Society of North America (RSNA), at the annual meeting in 2019. She asked radiologists to seek to create a more direct connection with the patient. For her, radiologists need to examine patients' experience more closely and ask themselves how they feel, what they want to know, how they would like to be treated. “It is necessary to create a new culture of interaction with the patient within radiology", she says.

We will take greater steps in the next decade to play a more integrated role in patient care. ” -  Jonathan Flug, MD, musculoskeletal radiologist at the Mayo Clinic in Phoenix.

Returning to our initial question: what will be the main role of Dr. Rafael and his fellow radiologists going forward?

Global access to more powerful computing, 5G and greater connectivity will further democratize medical knowledge and experience. This will lead to a future where all doctors (not just radiologists) will develop specialized knowledge in medical images in their daily practice with the dissemination of experience in diagnostic imaging by technology - eliminating the need for interpretation and delivery within the domain of a specialty totally separate from the way it happens today.

In the next decade, it will be the personal skills of radiologists that will make us valuable individuals in the health field ”, believe Arun Krishnaraj, MD, MPH, professor radiologist and head of the imaging division at Virginia University. “It will be our ability to integrate and navigate the vast treasure trove of data in a variety of silos to be in the nexus of health that will make us the drivers of decision-making.”, He adds.

Instead of being the radiologist who interprets more and more images and in search of a shorter response time, Krishnaraj recommends that direct communication with patients be improved, improving consulting skills with doctors in other areas and shaping collaborations with pathologists , geneticists and other specialties. “And at any time"He says,"be willing to embrace any new skills that appear"

The radiologists of the future will act as information specialists, putting all the information from different AI systems into context and using it to consult and communicate with doctors and patients. They will have many more tools to review studies with patients, give results and feedbacks snapshots and patients will have better ways to access their images and results.

In the face of so many uncertainties and challenges, we want to invite you to navigate these changing times, together with the most prepared and active professionals in the area of Radiology and Diagnostic Imaging who will be present at the 49th edition the Brazilian Congress of Radiology and Diagnostic Imaging, which will take place from the 4th to the 11th of October 2020, facilitating the generation of knowledge and scientific and professional connections.

See you there!

By: Lília Porto (author) and Raphael Aguiar and Dr. Leonardo Aguiar (editors and reviewers)

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