Evidence-Based Medical Practice-How Accurate is the Doctor's Interpretation of Radiographical Images?

X-ray image of an internal carotid artery aneurysm.
 Image credit
Mayfield Clinic

I heard a story of a doctor, a neurosurgeon, who operated on a patient to remove a brain tumour. The preoperative management of the patient was carried very well under this doctor's supervision; but the patient died a few days after the surgery. A post-mortem examination (autopsy) was carried out on the dead patient and it was found that he died from the rupture (very highly possible the neurosurgeon ruptured it during the surgery) of an aneurysm (a condition in which a part of the wall of an artery become inflated like a balloon because of the presence of fatty deposits in between the layers of the wall of the artery) of one of the internal carotid arteries and which has been there before the surgery was done. But this patient was said to have received a good preoperative management, meaning that he underwent X-rays, computed tomography scan and even MRI (magnetic resonance imaging) of the head and neck. Why did the preoperative management team fail to detect the internal carotid artery aneurysm? And why did the neurosurgeon also fail to detect and avoid rupturing it during the surgery?

In Nigeria and some other countries of the world, I think there are two reasons for this costly mistake. One is the poor relationship between the various members of the health management team: this is the major problem facing the healthcare delivery of many developing countries. And the other (which is not really an issue of whether the healthcare system of that country is advanced or not and hence is global) is the human error, an occasional drop of imperfection in that ocean of precision of our care of the patient.

A GOOD Healthcare Team. Image credit to
St. Mary's Good Samaritan Hospital

A harmonious relationship in the multidisciplinary management of the patient is a precious jewel that has been very difficult to mine in the healthcare system of some developing countries. The major root of this problem is the clash of egos among the various professional disciplines that make up the medical management team. With each profession clamouring to be the leader of the team; with some experts in one profession looking down on and treating with contempt the experts in some other profession---one sees a situation where a neurosurgeon verbally insults an anaesthetist during surgery in the theatre, telling him or her that they don't know anything and that he could teach them everything about anaesthesia; a situation in which a surgeon who is not sure of what the details are on an X-ray does not seek the expert advice of the radiologist for proper interpretation before going in to open up the patient, because he feels he knows everything about radiology in addition to his own area of expertise. Fortunately, everyone in the medical management team in this part of the world is beginning to identify this problem and realizing that it is not in the interest of the patient for whom they swore an oath to take care of. Efforts are being made by every one of them to preach the message that each member of this multidisciplinary team is indispensable and that everyone is equally important in our duty of giving the patient the highest of quality medical care.

Perfection in the various protocols guiding each modality of management and care of the patient comes after a long period of repeated trials during which mistakes are made (and whose end-product sometimes is the death of some patients) and lessons are learnt. But the fundamental basic goal of medicine is to give the best care to the patient, which can only be achieved by averting all possible errors that abound in the protocols of each form of patient management and care.

Technology has long been employed to help out in this area, leading to rapid advances in various areas in medicine and which in turn has greatly improved the quality of patient care. And as technology advances in itself; it magnanimously extends what it has gained to medicine. This gesture of generosity was recently witnessed in the area of interpreting X-rays of patients. A group of  medical doctors and IT experts in the Nuclear Medicine department of the Northern Ireland Cancer Centre in Belfast have teamed up to develop an iPad application called Experior, which detects where a doctor is making a wrong interpretation of a patient's X-rays. Experior, which has been reviewed by the Royal College of Radiologists, works by assessing the doctor's ability to interprete X-rays of patients taken in their hospitals through online and real-time comparison with a huge database of similar X-rays validated over time by experts who are authorities in the fields of Radiology and Anatomy; it then sends an instant feedback of that doctor's interpretation to him, highlighting the professional rating of his interpretation, giving him corrective analysis of the interpretation and clues on how to make a better interpretation of subsequent similar X-rays.

Experior Medical App on the iPad. Image credit to Experior Medical

In addition, Experior provides a vast online database of X-rays of the abnormal human anatomy as tests which the medical student, junior doctor and consultant can take, in a time-constrained setting similar to what obtains in the accident and emergency department, to improve their skills at making accurate interpretation of these images and saving patients' lives through properly guided medical care.

The Experior medical app can be used by anyone in the medical field in any part of the world; the only constraint for now is that it is only available for the iPad. If the Experior
Medical group can extend this application to the Android OS, then more doctors, especially in developing countries will have access to it. This will help to avert wrong interpretations of X-ray images, saving patients' lives.

Smart Education Curriculum: Bringing the Extra-educational Means through which technology trends into the Classroom.

Smart Education in South Korea. Image credit to Advance Technology Korea

I can't remember who I was discussing with some time ago but one thing I got from the conversation was this in my own paraphrase: people born in this technology age cannot do without or (get to the very highest level in harnessing their full potentials) without technology, be it in their jobs, startup companies and, which is the focus if this piece, education.

Many developed and developing countries' governments and private corporations are making efforts in bringing technology into the school setting-by providing tablet computers stuffed with books and 3-D interactive materials for the primary and secondary school students; the higher institutions are not left out of this. And this has greatly helped the students to develop their potentials in their school works and projects.

While these successes are being recorded, I still believe there are much more rooms for great improvements. Yes tablet computers with all the materials have been provided (they are helping because we use our PCs and ipads to play games, watch movies and listen to music; and hence there is a very high tendency we'll always study and work on our school projects using them). However, having incorporated the tools of technology into our education (though here in Nigeria we still have a long way to go), we're neglecting the means through which technology is permeating its way into the favorites and choices of the everyday life of young people (the main segment of the society fully immersed in the educational institution).

But before I hit my target, I give an illustration. Here in Nigeria last year the universities' lecturers embarked on a 6-month long strike demanding as the major priority improved funding of the nation's universities which are owned by the government. After so many negotiations, the lecturers' body and the federal government of Nigeria signed an agreement in which the government endorsed to pump in #220 billion ($1.3 billion) annually for the next 5 years into the universities for massive infrastructural development and other upgradings. While I hailed this achievement, I discovered another problem (wahala in the Nigerian pidgin English): the hardware (the infrastructure of our universities) of the problem is being addressed, but nobody is talking about the software (the lecturers-I mean the way these lectures deliver their lectures to students).

In most Nigerian tertiary institutions, some lecturers, I'm sorry to say, are luddites (ludite from Ned Lud one of the workers who led a protest against the industrial revolution in factories in the early 19th century when machines were taking over the works done manually by workers) and old fashioned in even the knowledge base of their specialty: imagine a lecturer detesting the use of electronic boards and projectors in teaching students; students using their phones and tablet computers to read, reminding them that in their own days they carried their big books to the libraries and read them from cover to cover. Another set of lecturers would teach students with notes they made in the 1980s and 90s and expect them to give them back in exam exactly what they taught them: if any student dared including new stuffs and updates as regards the particular course such a student might fail the course. And so this is the wahala I saw after the strike issue. 

Smart Education: personalizing teaching to student needs. Image credit to Smarttech

The world is changing and the knowledge database of each discipline is expanding at an incredibly exponential rate because of the rapid advances in science and technology. And for the disciples of each of these areas of knowledge to keep up, the tools of technology and the various means through which these tools are used (especially in the extra-school setting) are indispensable and must be incorporated into the academic learning setting.

Efforts are already being made in this direction (educational games and so on). Another strong extra-school means through which tech tools are voraciously being used is the social media-Facebook, Twitter and so on. This can be incorporated into the educational curriculum (but how many teachers and lecturers will agree to this at least in my country, Nigeria?.....That's the problem). However, some teachers, not in Nigeria unfortunately, are already experimenting this idea. According to a report on the New York Times, some high school teachers in Iowa, US are already experimenting with incorporating social media into classroom teaching and discussion in which students use Twitter to contribute to discussions on various topics in class, and some of them have recorded increased participation of their students in such discussions because social media (in this case Twitter) which appeals to them has been infused into what otherwise was a boring topic to them. The report also highlights some universities which have developed their own on-campus social media forums for academic discussions.

Though there are many critics of this approach, and it is understandable as there are tendencies of distraction, but it is still being experimented on and can be improved on. One such way is to configure such forums to monitor and indicate when a student has strayed off the subject of discussion ONLY DURING THE CLASSROOM DISCUSSION; it will possibly get better with time. And other social media like Facebook can be incorporated by schools and universities; and universities can develop their own online discussion forums linked to Facebook, Twitter and other popular social networks to be used as part of some classroom teaching and discussion.

I hope universities here in Nigeria can embrace this modality as one of its teaching methods. There are signs they will with time; one sign, though it is still at the student level, is the social education network Acada360 co-founded by Mr. Godswill Oyor, a Law graduate of my school, the University of Ibadan. Acada360, I will say is still evolving, is where students in Nigerian universities can upload their notes taken by them in class and get rewards when other students download them. I got to know about this site today on Instagram. Social media technology has come to stay and rapidly advance and our school curriculum must capitalize on its positive prospects.