CAD in Radiology: the Cyborg Advantage

It was ages ago that I was standing, a little bit excited but not about to admit it, on the ward for the first time: a real medical student. My white coat was crisp, fresh, new and a dead giveaway to my newbie status. My Littmann stethoscope worn in the self-conscious style in the way doctors did, draped like a scarf carelessly over the shoulders. In my pocket: the Washington Manual. It was an ancillary brain - the source of all one needed to know in the moment. The resources of the library not available until later, if one could sneak away to seek greater knowledge, to create a handout for rounds in the morning - something to refute the dogmatic wisdom of the JAR, but never to challenge the attending. 

Such was life in the 1980s, a world just after of the era of The House of God.1

Today, the iPad and the iPhone are the ancillary brains of the students, the house staff and the attending. Google scholar at a touch. Drug doses all there, differential diagnoses at a flash. No longer could I convince the team that a vegetable fiber in a stool specimen was a worm. I would have to show them a picture of a worm, and the most loquacious of chat could not convince them without a picture. Bravado does not get you where it once did.

Today we are living in age of fusion of the human brain and the machine - in essence, the cyborg. The man meets machine era is here - now and more and more in the future.

As radiologists we live by technology and die by the same sword. Where would we be without CT or MR, never mind PET/CT, a dynamic intersection of form and function? Yet, as a profession, we are reluctant to embrace change. But change will come whether or not we embraced it.

As doctors we hold peoples’ lives in our hands. As imagers we excel at pulling a whole story, an entire patient, from a series of pictures, often black and white, sometimes in color. We recreate a real person from the images in front of us, telling a story of the athlete who fell and damaged his knee - will he play again …this season…ever?  The young mother with breast cancer, with positive nodes but no distant mets… or did we miss one?

Statistics are scary. Some studies say that up to 30 percent of our reports contain errors2.  Leonard Berlin sites a much lower number - around 4 percent. Yet if you think how many studies we do every day, either percentage is a lot of mistakes - mistakes that are often obvious to us in retrospect, so obvious we can’t believe we missed them. One former colleague  who was sued for missing a one-centimeter tumor on a CXR, gave the defense that he never read the case. The finding was so obvious he could not have missed it.  How do you think the verdict went?

We all agree that we want to deliver the best care to our patients, submitting a reliable report - not usually, but without fail. As we strive to approach this goal, we need help, because we are not even close to perfect. Yet in radiology, a field defined by technology and one that would not exist without sophisticated scanners and amazing imaging technology, we are slow to adopt computer aids in our day-to-day life.

What about CAD? If we wait, saying that CAD stinks and we don’t like it, it will be developed in spite of us, but not in an optimal way to help us deliver the best possible care. To ignore the changing world around us would be like eschewing Google for the Dewey Decimal card file. The challenge is even greater for those of us in the private practice world, where residents are not there to smooth the bumps of imperfect technology, allowing early adoption of even suboptimal advances.

Where is CAD today?  Well, for sure it is not here yet. Despite widespread adoption of CAD in mammography it has not been embraced enthusiastically, and although it may increase cancer detection, this comes with significant increase in recall rates. In the lung - for sure not yet. Colonography? Pretty pictures for sure, and help some, but a clear-cut advantage? Not yet. 

Men and machines process information differently, and together they may provide more than the sum of the parts. Take that momentous day in 1996 when a computer trumped a chess master. In answer to that failure of man, the chess grand master Kasparov created advanced chess, a game that allowed players to use off-the-shelf computer programs to play against grand masters and machines. Ordinary chess players, using this readily available technology, trump either chess masters alone or machines alone - a type of cyborg victory. 

CAD is not ready for prime time yet, but drawing on the thoughts of Hipp and colleagues, as they looked at CAD in pathology, the future may well be around the corner. Harnessing the power of the machine-man interaction may be the key to effective implementation of CAD, effectively increasing accuracy in our radiology reports.

We are not there yet, but the days of the Washington Manual in one’s pocket are long gone, and as a profession we need to embrace technology to improve our workflow, optimize our accuracy and leave us some time in the day to enjoy our work.  Let us actively partner with technology to make sure we are driving the process, and not let it drive us.

What do you think?

1 Samuel Shem, The House Of God, Dell Publishing, New York, NY, 1978

2 Kruponski, EA, The Importance of Perception Research in Medical Imaging, Radiation Medicine: Vol. 18 No. 6, 329–334 p.p., 2000

Disclosures:

1 Samuel Shem, The House Of God, Dell Publishing, New York, NY, 1978

2 Kruponski, EA, The Importance of Perception Research in Medical Imaging, Radiation Medicine: Vol. 18 No. 6, 329–334 p.p., 2000