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Digital lessons learned from musculoskeletal radiology
Patrick Omoumi
Friday, Feb. 1, 2019 · 11:37 a.m. · 27m 18s
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uh with former actually
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thank you very much for uh for inviting me the last uh it's always a pleasure to go uh
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speak in front of an internal does not been doing a lot leave his thanks to you
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so uh let's see what uh oh what um i can tell you
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about the perspective of the radiologist looking at a high and
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just to give you um uh the atmosphere in which we have been living the for
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the for a past for four years or so uh let's look at this uh
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video
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so
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it's it's it's it's it's
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ah she is just it's it's
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i i ah
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ah
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so a disguise actually uh uh one of the ah constant beacons in that computer
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science it's a a works uh it cool also teaches at university of toronto
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and and what is says we should stop of a training rejoice
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we don't need anymore george's because yeah we'll take over
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is uh is not the only one to think so uh now if you look at the business side
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of things uh people like famous influence there's like a few not cost lab a venture capitalist
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uh was a given an interview in this paper and i start reading it for me was like roller coaster so uh
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so first line he says that the role of the radio this would be obsolete in five years and i wasn't too doesn't seventeen i think
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um so i started the to count the the years and i almost pick up my
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phone to call thomas please take me as a reason to remotes elegy i
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and then i kept reading and the next the sentence was a machines would replace eighty
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percent of doctors and i was like okay so what do we do now
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and uh actually the journal this went to san says stanford
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and san francisco and ask a few radiologist or what
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they think of all of that a. i. n. and so on and the radio to say that their jobs
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we only become more important with air out so i start to breathe again this might come back on my face
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but nevertheless this is what we've been hearing over and over
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again a i will threaten other jobs off radiologist
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so what i'm gonna be telling you in the lesson next uh fifteen twenty minutes
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is we're gonna try to see if the reason room for optimism or not a former with all this perspective
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in order to understand this or to answer this question will see what do what a i can do
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for us as we all just how we would be impacting our work flow our daily work full
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and it's called without saying that there are limitations and challenges ahead
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of us as well in integrating i now work flow
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and i will go a touch upon that were briefly as well let's start a little bit of um historical perspective
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a religious have been fully your steak is actually trying to find a ways
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for computers to help them improve the way they work be more efficient
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being a a more accurate this is nineteen eighty nine uh a peep a paper
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on the problems in applying expert system technology to the interpretation of requests
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and the problems they had at the time were the very different from from what we have now
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there were asking themselves how the ritual utilities to fit should phrase
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the the abnormality that b. c. to putting in the computer in the right way
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for the computer to tell them the right diagnosis so that was very primitive
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thirty years ago let's jump back in time ten years ahead of
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that so nineteen ninety seven that was um the paper
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written in one of the most influential journals uh in our field uh
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uh that was called can machine learning or can machines to learn
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to interpret read about so that was already uh the question that was asking that they're asking them selling a twenty years ago
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and in this paper the uh our asking does this mean they're they're risking expect to be replaced
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but network machines in a new feature answer absolutely not to that was already optimistic by then
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but they were saying that uh in the next decade we will
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likely produce network based system that eight we deal or just
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by previewing the images in and helping them basically uh improve the work flow
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that was nineteen ninety seven now let's move on to in two thousand
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seventeen to present times uh what is what is happening today
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the if you look at the literature theory was this a review
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paper uh that looked at three hundred over three hundred papers
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in part meant um where do you look for a publications on a on a machine
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learning deep learning in medical imaging analysis and this is uh what they found basically
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an exponential increase in the number of papers in that field and exponential means basically
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the that was options as to doesn't seventeen most of the papers were
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published two dozen fifteen sixteen so the next free day you're sorry
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every modalities are concerned as you can see him rise city and so on and
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so forth different uh techniques segmentation detection
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classifiers uh i've been a used
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and a surprisingly pathology was first in the top of a of
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the fields were most affected pathology also have images microscopes
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but a different field in an an radiology brain in someone absurd for me
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i was surprised to see that blown imaging was not so highly
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ranked and actually i did uh i just finished a right to review one on m. s. k. a. i. m. es get radiology
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and if you look at the papers that were published up to the end of two thousand eighteen there was only thirty papers
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i know i miss kate radiology so up arthritis detection and so on so forth
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um so it it it's it's lighting a little bit behind a i. e. maybe we'll have time to discuss the reason why
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um so it has been a hard topic it still is a all the more our
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topic today since the advent of deep learning in and in the past few years
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and if you wanna look at how the radiologist will is seeing the impact of a i nice work full
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let's look at what we do in our daily lives so we receive a request from a clinician
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we uh manage this request we look at it decide what to do with them a lot
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is correct or not we schedule a we schedule the appointment and then reproduce the images
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um there's a few steps here to uh puerto calling deciding how to do how to perform the images and so
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on and so forth we interpret the image that's produced make a report transmit to see a couple franklin issue
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first step managing to request an schedule like
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does the patient has allergies to a conference media that's something
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that's some clinicians uh forgot to tell us about
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so we have to be certain above of that before we start the the main
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uh the examination before we choose maybe switch modalities be depending on the answer
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patient as a pacemaker and so on and so forth piece can become completely automate size especially using
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a language a language classifiers so that's something we
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are actually hoping for and and we're waiting
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um then we need to decide if i have to do a more i have the of the ne what's sequences what
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planes will uh if i need it contrasts midi or not
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instruments of course i first years of question last myself
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and and the answers is based on what uh i'm looking for so what
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i'm looking for a and unfortunately the conditions are very good at hiding
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us the not the correct information that important information for us at another work they want to test us every time the ice 'cause it
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an exam so um so this is also for us a very
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important uh in a i can have a huge impact
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in terms of uh decided to helping us decide how to protocol in can be automatic so if you uh
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a look at this algorithm uh it did look at the full text of a clinical indications of the study
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and they decided whether now uh injection ivy contrast was needed or not in
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eighty percent of the cases why would the accuracy of eighty percent
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and uh other uh applications uh exist uh that's
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something we are actually hoping for a um
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i have acquired the digits they're men now i need to reconstruct the
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raw data so i put my patient in in the m. r.
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and i have raw data to uh to play with and to to to build an image from
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if you have a meaning if you're aiming at having such an image this is or
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crawl view of an e. m. r. i. uh this is a zoomed in view
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you can now using generally if a i models uh acquired
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this which is a much faster law requisition a image
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and then from band from that build this so using models a.
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i. models you can be very close to a high resolution
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uh image so that's quite something for us it's a it's a it's something that's very very interesting in terms
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of uh increasing the resolution over images becoming faster right acquiring them and so on and so forth
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it was a very interesting papers published um they looked at how how does generative models can
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can switch basically ten can get the information from one image and and predict the
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another sequence for example let's start with the non fat suppressed to to sequence of the spine here
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you see that the fact is not suppressed a that would be the fast
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suppressed image that you acquire this is the output of the algorithm so
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basically from that it constructs that it predicts that which is very very similar
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to our target it's not perfect but it's extremely similar even crazier
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you give them a really rough
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people in more
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i could not believe it i was uh i was shocked uh it a date from that they did this
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so um i don't know i'm i'm really curious to see what else they can do a it's it's
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it's not perfect if you look at this c. area here it's not exactly the same but it's it's
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it's the the potential is enormous enormous and and actually the question is we we actually need
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to look at these images uh or can we just uh um deal with the raw
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data but that's that's for the very like long term for sure i guess
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image interpretation that's the next step of my of my daily work flow uh i have
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the image i need to uh decide what uh what the diagnosis is and and
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lesion detection is the first thing that comes to mind when people think of a i apply to radiology
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and that machines can do better than than human beings and for most
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of it like the asian detections typical example would be fracture detection
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uh the there is an error a misinterpretation of average emergency missing functions by
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forty seven percent so they feed the algorithm with the experts analysis
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the all rhythms apply to relax the uh and they perform the algorithms perform
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much better than the average commission so that's something very very promising for
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to implement uh to increase the the the efficiency in the performance of of all the
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doctors who are not experts in those fields who have to deal with these images
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uh other applications you for example you have a stack of mammograms you're doing a
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mammogram uh uh a console today and we have forty mammograms to look at
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most of the mammograms are actually normal in a in a hopeful i mean thankfully so
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um but if there's one had normal mammogram you prefer or
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looking at it while you're not digesting relaunch right so
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you can pretty digest yeah i can pretty digest those images put it at the top of the list
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and you know that this one probably is abnormal so i'll go look at it when i i
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just have coffee and and i'm awake basically to look at it and not miss it
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that's something that's very important um you have a stack of c. t.s acquired at the emergency room
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and uh one of them has a a a has an abnormality
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and and before uh if if you wait two hours uh it's it's
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it's it's it's a shame so you can have this image flight
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put at the top of your list and take care of the patient very urgently so these are the applications that uh we um
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we see but image interpretation does not only mean looking and image and making a
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diagnosis it uh uh this is a patient i i had looked at
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two days ago fifty five year old woman with long burping this is the information i had
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and i look at this i saw this no idea what it out with it
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so because i know that clinicians they want to hide information from us
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i went to look at digital records and i find out information
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of interest information breast carcinoma dispersion as history of arsenal
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i forgot to tell us um and actually the pain was will be lower than when nice what
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that what what is this but i know also that it's not always reliable but the
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commission tells us the l. four or five in the hands of remote all this isn't the
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same as a in the hands of a of i don't know a dermatologist so uh
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more questions and uh and i see i think okay maybe i need to look
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at uh at the previous uh data and see if this was already present
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i look at the list of of the images thirty exams for this patient in my pack system
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i assess part one that could be interesting for me to put city from today two years ago
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i look at it and go down and this something here that might be what i'm
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looking for but i can't really compare those two images i need to have
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said it'll images to do that i need to go out was that close exam
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real open it again to re formatted in uh in this as a plane
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reformatting scrolling panning zooming windowing five minutes later i have this image and
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there is something you are not so not sure what it is
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but now i can have the information at hand to decide what to do to another examination or follow up or whatever
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it took me twenty five minutes to think about this case and all of that
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could have been ultimate ties with yeah i and that this is something uh
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uh i'm not even talking about um a quantitative him a analysis of images this
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is something we need to do with you wanna do proper research or even
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that's with our patients probably we need to add quantitative what
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the same a quantitative a day that you know reports
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time consuming cumbersome nobody does it uh the t. two mapping to look at
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the composition of college is all this that i had to go through
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to build this image you and get a value for uh to to mapping fifteen minutes nobody that
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one image every two seconds every working day for an entire this is uh the live coverage
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or just and i'm sure they must be a better way to do this uh a
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soul that's why probably if you look at the uh public opinion in these days if you
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look at the if you wanna know the public opinion something you look at treats
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you look at two years three or six hundred and five squeeze a by four
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and seven users over one year uh that included a i in imaging
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um most of them are very positively we already recording uh considering
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yeah i i never george's so i eighty eighty percent
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and not very few we say that a i would replace with all just
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with vision seemed work for improvement are the main uh uh things that come up and limitations of
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challenges and i want to briefly touch upon that uh because i think it's important so
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two risks with a i we already talked about it earlier just to today is really depending on on how you
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feed the algorithm if you don't have good or if you have bias input you gonna end up with disaster
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there is it's very easy down days to build an algorithm that can
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label uh images you'd feed them with images that are labelled
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you teach them how to label the images and you get an answer for new set of data out new sort of images
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they did this test with a a standard uh yeah i which was exposed to images from google
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and then uh they build the psychopath i'll go with them
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which was fed by images taken from the dark what okay
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and then they they asked them to a label this image for example
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the standard a. i. c. is a group of birds sitting on top of up to re backed branch why not
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look at this one
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so depending on the data you feed the algorithm the result can be
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extremely different right not to say that it's this is a paper or thirty first to generate it doesn't nineteen yesterday
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if for example for patients to worse after organ
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transportation or after receiving chemo friends this cancer
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machine learning algorithms may conclude such patients are less likely to benefit from for the treatment
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and we commend against it so again if you take it data and you can buy
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sits in some sort of way you end up with a disaster um liability issue
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somebody has to take responsibility for for with the machine says and as of today i don't know
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many people in this room who wants to go on the flights with no human pilots
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uh in the flat i know we know that's last last uh aeroplanes can fly at all
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uh we actually probably need somebody sitting in this the seat and and uh
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and that's very important to to have to convert the patients and the
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radiologist the pilot can talk to the to the to the
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'kay can be the the gap between the bridge the gap between knowledge
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and and uh and and reality you can if there's a turbulence
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i wanna hear if human voice telling me there's a turbulence i wanna know all that is located the plane is doing this
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and and and i wanna hero human voice a reassuring human voices
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you and into the pad doesn't give me this information i
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stress for like fifteen minutes like what's going on so it's something that really need the need to uh
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when we have to have that in mind i'm gonna go over that very quickly because it's so
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in terms of health care artificial intelligence we we all
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this we look at as augmented intelligence we needed
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to improve our fifties that's something very uh very uh important and that's end up on this not
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thank you very much higher
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hi thank you very much soul scary in exciting the same time
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so when we see a whole the possibility good summaries
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so it's like a used to hide in the yellow
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with drinking decided whatever sell ah questions please
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when i got to move on until i get half he's one question from the floor
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yeah but it that's cheating
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i just um put some protects you know my tastes in in m.
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arrives any how far we this be nice to have huh
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automatically it can be done to morrow but like that but again or is it not of interest could be done if you have the right data
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and you have the proper labelling okay depends on who you check to label data
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if you wanna pay an expert like me very expensive yeah or if you
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wanna have somebody your kid for example do that uh after school
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so it's really is a lot of issues in terms of like yeah during the right data we already talked
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about this morning but when is m. s. k. compared to um um colour g. in automatic image recognition
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why or where where are we sell like i imagine the demo applications now for cancer
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i'm not exactly so one of the main hourly and yeah yeah that that
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again so like one of the next things that can uh it
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being implemented is the detect automatic detection of long nodules
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for a screening a lung cancer and this is something like probably it's gonna happen in within five years or so
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but for that you need registries approaches repositories of of patients with follow up and and we know
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that this patient have this not will develop into cancer so we have to which respective analysis
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any any cancer lung cancer with this it this is something that we have to do yeah
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already and and it's not doesn't takes all so much effort to to an ally set
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these are the areas where we will be forced to using a i
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i i i whenever you go into deeper or a complexity
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it's gonna in my opinion we not there in the for ten twenty years
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but again a eyes not just looking at images in diagnosing a eyes also a
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language recognition language analysis and this can be a lot of help for us
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so what is the taken busy age i pro all the calls
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of knowledge i'm this life sure you don't agree i mean
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i wasn't clear enough or you try to push a few to be too far away when you hear twenty years
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twenty is was so we think it happens but she was gone to a computer is some other things
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goes so fast it's the years you will flying plane without any point that's
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a psychologically speaking almost okay but they would have a nice voice telling
00:22:04
you everything is fine yeah probably i know it's a computer even you cheer
00:22:08
we just i'm not stupid i know it it's okay easy but
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for the which at you to smoke something in the plane so the okay
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to answer the question i think the question is not if i'm pro
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or con uh there was a paper in two thousand and this month
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in radiology which is our our journal saying resisting is for china
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it is no i question it's gonna happen so i i it's not offer made to
00:22:32
resist something that is gonna happen so the question is how we wanna make it
00:22:38
uh how wouldn't we wanna use it for our best interest for us for
00:22:43
the medical community in general and mostly formations of course of course
00:22:48
alright thank you very much thank you idea oh one question one okay yes i get one
00:22:57
and thank you patrick for your very interesting a presentation um maybe function is for for
00:23:03
what you you you say yeah we need some collaborative uh work uh to
00:23:08
help uh to support 'em doctors and you in this evolution do you know the
00:23:15
i. e. they any uh people of
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a specialist of informatics data management
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um i i a. e. engineer who work with doctors like that or what we have that
00:23:28
issue have that or yeah yeah we just hire the person was the king himself uh
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uh is actually siemens employee but yes seventy percent of the salary come from the really off department
00:23:38
any as well i mean he also teaches at a pay fail uh has a
00:23:41
whole team around him and his integrate in the centre of biomedical imaging
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uh which is about thirty physicist uh developing sequences are and all that so these
00:23:51
people this a whole team of people in the radiology department at issues
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and i'm only talking about issues uh working uh you know that
00:24:00
the scientists that we have uh we just bought a
00:24:03
servers uh from the shoes to do that so it's yeah we have we on it right
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short questions so in the clinical parks is one of the most important thing
00:24:13
is to compare serial images show you the the food to your room
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twenty five minutes to try to find a needle in the haystack show
00:24:21
why is it so with a difficult to just the question i'm asking myself every day
00:24:26
you don't understand why is this is not automatic yeah two dozen nineteen i can talk to my
00:24:32
phone in and make as a you know a task for restaurant tonight any bookings for me
00:24:37
and this a match is not aligned averages are probably it's it's just uh you know it's
00:24:43
one of the issues also like this the business is slow to grow uh uh the the the
00:24:47
business partners they are the legislation around all this whenever you have to look at the image
00:24:54
this so much regulatory stuff to go through before you implement software new software
00:24:59
takes forever takes five years so so in in one of the things that we need
00:25:03
as with george's i was talking to one of the colleagues uh at the break
00:25:07
i don't want to stand up for my computer go to another computer do a software
00:25:12
analysis that that that's not available in my packs go back to my packs and
00:25:15
and reporting with a computer i want everything to be integrated because you need that
00:25:19
integration uh it takes time wriggle two issues and so on and so forth
00:25:25
um i think the diagnostic accuracy of any taste
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not only depends on a tuesday tilted discrete
00:25:34
you were diagnosed a gal rules more interpretation aged
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eulogy but it depends also on the pretext
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um frequent problem and probability in other words the person it's re
00:25:46
for you the patient how to well groomed account for that
00:25:51
well they will have to confirm that uh that's for sure
00:25:57
that's that's a whole you know why would we talked about the us
00:26:00
when you arthritis issue and and uh the uh classification uh
00:26:04
criteria were talking about it at dinner last night at the talk i was giving and is your last year
00:26:09
uh uh it's it's all biased like you know do you use the
00:26:13
criteria that's a lot to classify patients in a in a
00:26:15
specialised environment and you apply those criteria to make a diagnosis in
00:26:20
a normal way uh uh you know normal uh context or
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that's why i i personally think the human factors to bear important
00:26:27
to leeds dialogue and before an algorithm can probably not
00:26:33
always replace 'em every year every radiologist i'm convinced
00:26:41
about that yeah i i hope i'm right
00:26:44
thanks i hope for you to so thank you very much time to move on
00:26:55
is the next speaker posters alton could tell it from a dozen university
00:26:59
an interesting because for me to list the conflicting words in the same
00:27:03
titles so that be very good to learn is big that i'll
00:27:08
and rainy bongo rate disease so is like a rate data always big that also had the
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