Ronald B. Schilling, PhD


Remember those 78 vinyl records that had amazing sound. It was true that you could hear some noise, but, it was not really a problem. Actually, the sound quality was such that a well-informed listener would "hear through the noise."

What we may not have realized at the time was that the bandwidth was wide enough to impact our senses through both the music and the “feeling” of sound. With the right speakers, we got it all. Having worked at RCA Labs, in the early 1960s, I had the opportunity to buy a pair of LC1As - the professional recording studio speakers. High compliant outer surround on axis tweeter and woofer; all that good stuff. It was truly amazing when coupled with 78 vinyl records.

Then came digital music in the form of CDs. The convenience, such as portability, changed the game and the CD craze significantly impacted the sales of 78 vinyl records. Interestingly, today, we have two simultaneous shifts taking place. Streaming is now the latest craze and, therefore, CD sales are down. However, sales of vinyl are up as people are realizing that they have been missing the excellent performance associated with the quality of vinyl records – despite some noise.[[{"type":"media","view_mode":"media_crop","fid":"45426","attributes":{"alt":"Ronald B. Schilling, PhD","class":"media-image media-image-right","id":"media_crop_660559034193","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"5206","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 144px; width: 180px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"Ronald B. Schilling, PhD","typeof":"foaf:Image"}}]]


Remember those X-ray mammo images that came from systems that could visualize all 16 artifacts in the ACR-NEMA phantom. What we may not have fully realized at the time was that the very high spatial resolution, responsible for seeing the phantom artifacts linked to visualization of calcifications, was a very significant element in the overall patient results that were obtained.

Then came digital mammography, which soon started to dominate the market. There wasn't much attention placed on the fact that all 16 artifacts on the ACR-NEMA could no longer be seen. The ones missing dealt with spatial resolution - the ability to see fine calcifications. 

Interestingly, there were attempts at systems that could see all 16 artifacts on the ACR-NEMA phantom. However, they required the use of line scanning and could not compete with the convenience of area scans, even if the performance was being compromised.

During the last several years, tomosynthesis has come into play in mammography. In some ways it parallels the music case outlined above - the desire to get back to the performance of old using new technology. At a recent panel discussion of experts in the field, tomosynthesis was predicted to become the gold standard for X-ray-related imaging in mammography.

There are a few messages that we can glean from music and mammo. One is that performance will eventually be "rediscovered" as new generations come into the game. The amazing thing is that it can take such a long time to go through a complete cycle. This is especially true in the medical case in which gaining adequate evidence for new technology takes much time and a catalyst of a new technology (eg, tomosynthesis) is required to get the market "back to the future."

Articles

Advancements in music and mammography follow similar paths.

What Music and Mammography Have in Common

A broad characterization of Moore's Law is: "the driving force of technological and social change, productivity and economic growth."

In the field of medical imaging, we are embarking on a very exciting period driven by a combination of very tough economic constraints and the birth of some of the most powerful visualization technologies, which have the potential of meeting the economic constraints head on.

This dynamic fits perfectly into Moore's Law as described above. The driving force of technological change is interactive holographic systems (IHS), a combination of stereo and virtual holography that allows the user to work with objects in 3D/4D open space as well as with standard images (2.5D).

The economic constraints are based upon the demands that medicine is facing due to the Affordable Care Act – focusing on maintaining or improving patient outcomes while significantly lowering costs. Cost reduction can be achieved through increasing workflow. In turn, increasing the knowledge of the user can effectively increase workflow.

By combining stereo with virtual holography, creating an interactive holographic system, it is possible for doctors to visually work with parts of the body in open 3D space as if they were real physical objects. With the addition of various approaches to directly interacting with the object, it is believed that both cognitive and intuitive skills will be improved due to the use of these sensory cues. This will result in a meaningful increase in user knowledge and hence workflow.[[{"type":"media","view_mode":"media_crop","fid":"27653","attributes":{"alt":"Ronald B. Schilling","class":"media-image media-image-right","id":"media_crop_8514987972665","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"2721","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 120px; width: 150px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":" ","typeof":"foaf:Image"}}]]

Several examples of the above have already been demonstrated. For example, Dr. Frandics Chan of Stanford demonstrated simultaneous improvement of clinical efficacy (sensitivity increase from 81 percent to 90 percent) and workflow (reduction of analysis time from 22 minutes to 13 minutes) for a major arterio-pulmonary collateral arteries (MAPCA) clinical study that was presented at 

In a recent discussion with radiologists analyzing coronary arteries, the gains of IHS are believed to have the potential to improve workflow significantly (two hrs/study to 30 min/study) while improving clinical efficacy.

Another exciting technology that is sure to impact Moore’s Law is machine learning. Computer-aided detection (CAD) is a well known example of machine learning. In general terms, we are referring to using computer algorithms to convert data to information and then to knowledge for decision making by the user. A key element in successful machine learning is to be able to have the user annotate images so that the basic data can be gathered. Unfortunately, today, the process of annotation is very burdensome for the user and is therefore not done adequately.

This situation will change as additional technologies are integrated, making the annotation process seamless for the user. Examples are the combination of IHS (noted above) with voice recognition.

Moore's Law is clearly at work in medical imaging – technology impacting productivity and economic growth while resulting in social gains.

An argument that Moore’s law is at work in medical imaging.

Moore’s Law in Medical Imaging

Editor's note: Over the past year, Ron Schilling's commentaries in DI SCAN have addressed issues regarding business strategies in medical imaging. We are publishing some of the questions and responses rising from those commentaries, while inviting new requests for information.

Question: Effective implementation of new technology is becoming more challenging. How do we get ahead of the game?

Answer: Dr. Paul Chang addressed this question in an interview in 

Innovations offer radiologists opportunity to remain relevant

 October 2007). He noted that the availability of advanced visualization on thin clients creates both rewards and risks. The key to maximizing the reward (better services provided by radiology) and minimizing the risk (surgeons and other physicians deciding that they do not need radiological services) is for radiology practitioners to use the technology to provide additional value to their customers. That value can be achieved by adding consultation capabilities, specifically, virtual collaborations.

In an earlier article on the use of strategic thinking tools (

Successful technology implementation makes medical imaging tick

), we discussed how to achieve the maximum value from implementation of new technology. The bottom line was that members of the implementation team must modify their behavior while incorporating new technology to achieve optimal results.

As described by Dr. Chang, new technology is a combination of the server/thin-client model with advanced visualization methods and Web 2.0 for electronic communication. This is to be contrasted with the present technology of independent workstations tied to a PACS.

At RSNA 2007, it was clear that much of this technology is in place and more is on the horizon. The challenge for radiology practitioners is to decide that the only way to achieve virtual collaboration is to adopt new behavior by leveraging the Internet and electronic communication. The old (passive) behavior of using browsers to just consume information is not going to do the job in the future.

By using our 2 x 2 approach, we can provide strategic clarity. Consider these quadrants:

Old Technology/Old Behavior = Workstations (thick clients)/Browser mode of operation

New Technology/Old Behavior = Server/thin-client model/Browser mode of operation

Old Technology/New Behavior = Maximum collaboration with old technology

New Technology/New Behavior = Fully using server/thin-clients to achieve virtual collaboration

Clearly the process to follow is to attain the position of New Technology/New Behavior to achieve virtual collaboration and reap the rewards of the new technology. 

How to make this significant change? Avoid the extremely low value and painful condition of New Technology/Old Behavior. Unfortunately, much new technology implementation is paired with old behavior due to a lack of adequate training.

To ensure that we avoid New Technology/Old Behavior, we could decide to go directly to New Technology/New Behavior. This is often a risky approach. If the appropriate training and conditioning (changes in beliefs that drive changes in behavior) do not take place, there is a reasonable likelihood that we will end up in the New Technology/Old Behavior category.

The above suggests that Old Technology/New Behavior might be a good initial step on the road to New Technology/New Behavior. By modifying behavior at the start, one is in an excellent position to reap the full benefit of implementing new technology. 

 and president of RBS Consulting in Los Altos Hills, CA. Comments or questions should be sent to Ron Schilling at Ronald11341@aol.com.

Editor’s note: Over the past year, Ron Schilling’s commentaries in DI SCAN have addressed issues regarding business strategies in medical imaging. We are publishing some of the questions and responses rising from those commentaries, while inviting new requests for information.

Q&A: Implementing technology in stages

Editor's note: Over the past year, Ron Schilling's commentaries in 

 have addressed issues regarding business strategies in medical imaging. We are publishing some of the questions and responses rising from those commentaries, while inviting new requests for information.

Question: I was recently told that a good manager should be a good consultant. How can one be both?

Answer: Managers should learn to be consultants, objectively and meaningfully offering advice to both internal customers (employees) as well as external ones (purchasers of goods and services). But the advice they give may not be what you'd expect. Rather than offering answers to problems, consultants and managers should help their customers find the answers within themselves. 

I believe that customers always have the answers, because they are in the best possible situation to know what they are. Customers are immersed in an environment where they are dealing directly with the forces affecting their purchasing behavior. It is difficult for an external consultant to appreciate the situation as fully or completely.

What the customer doesn't necessarily have are the questions. This is where the consultant plays a key role - by guiding the customer to ask and then answer the right questions at the right time.

To get things moving, the consultant typically seeks to provide the right framework for customers to consider the issue or opportunity at hand. The framework can be one of the strategic thinking tools I've outlined in previous 

Before selecting one of these tools, it is important for the consultant to listen carefully to the customer and to think, "Which tool am I going to use?" A professor at Stanford, upon attending one of my lectures there, noted that a good metaphor for this process is the jazz musician. In jazz improvisation, the musician listens carefully to the chords being played and selects the right tool (a lick or motif).

If competitive issues are the main focus, for example, then the High 5 tool can be applied (

High 5 highlights the importance of understanding the competition

But if the customer is centered on how to achieve a major goal or initiative, the Vision Statement tool is appropriate (

). These and other tools previously discussed in 

 are designed to resolve various classes of challenges.

As teams utilize Strategic Thinking Tools, they rapidly learn to understand which tool or tools to apply in specific situations. When a similar situation presents itself in the future, the teams are then prepared to select the right tool early on, making for a much more efficient and effective process. 

Often, however, the trick is not so much knowing what needs to be done as it is providing the means to get it done. Being a consultant requires that you act as a facilitator. By remaining neutral in the discussions, you can ensure that team members will contribute freely and creatively. In my experience, an internal facilitator, often the manager, is a very positive force for achieving meaningful team results. By understanding the situation and the participants, the manager is in the best position to guide the resolution process.

The key to success, then, may hinge on choosing the best facilitator, as well as the best tool. If the manager feels uncomfortable facilitating, another individual can be selected from within the team. 

In a pinch, a facilitator - ideally one who has all the tools that might be needed - can be recruited from outside the company.

 and president of RBS Consulting in Los Altos Hills, CA. Comments or questions should be sent to Ron Schilling at ronald11341@aol.com. 

Author | Ronald B. Schilling, PhD

Articles

What Music and Mammography Have in Common

Moore’s Law in Medical Imaging

Q&A: Implementing technology in stages

Q&A: Consultant, manager -- or both?