Is a “Black Swan” Living in Houston?

By James E. Lewis, PhD

Black Swan technologies or events are characterized by surprise first. That is, knowledgeable observers, think there is no such “thing”, if, indeed, the “thing” has even been considered by them.  In this context, the term derives from how black swans were thought not to exist because only white swans were known in the 17th Century.  Discovery of black swans in Western Australia in 1697 thus came as a surprise; an unexpected occurrence in the natural world.  A more contemporary example is provided by the Pacific hurricanes that develop off the coast of western Mexico and the southwestern United States.  They were believed not to exist by meteorologists and climatologists into the 1970s when weather satellites began to provide both data and multi-spectrum images that could only be understood as Pacific hurricanes.

Medicine has experienced some Black Swans, too.  The germ theory of disease and Roentgenology could be examples. Historians of medicine and science and technology could argue about them and other advances that might meet the Black Swan criteria. That is not the purpose of this brief.

The purpose here is to bring to the attention of the broader medical community what appears to be an important Black Swan from Methodist Hospital in Houston that goes by the name “Computer Augmented Visualization Environment,” locally dubbed “Plato’s CAVE”.  According to the published information, the technology has been operational since April 2009 and, if adopted for widespread use and reaches its full potential, it should affect the profession at all levels from medical education through the most extremely complicated surgical and medical procedures that may be performed by any of the clinical specialties and subspecialties.  Space limitations force us to focus on the highlights of this technology.

Its technical architect, Paul Sovelius, Jr., described this visualization technology in “Plato’s Cave—Knowledge-Based Medicine or Black Swan Technology,” (Methodist DeBakey Heart and Vascular Journal, v.7, no.1, Jan.-Mar., 2011,pp. 27-34) The paper is fully illustrated with exceptional multi-dimensional color visualizations digitally created from conventionally-acquired, 2D gray-scale images of the relevant conditions of actual patients. The visualization system is indifferent to the image acquisition modality employed.  In theory, at least, molecular as well as regional and whole body images can be visualized.  This advanced clinical visualization process is the result of “a novel and creative assemblage of FDA-approved, commercially available, diagnostic imaging components.”

Visualization is quite different from the simulation devices that came into widespread use in health professions education and training over the past decade. The patients are real, clinician users make up their own “menu” of what and how they want to examine regions or tissues of interest, clinician teams can analyze and discuss the visualization and the patient’s medical record simultaneously, and, if desired, patient and physician can discuss treatment alternatives while sharing the same information.

The visualizations are not only multi-dimensional, but multi-modal, and in color.  Users find that visualizations are easily manipulated, including removal of overlaying tissues, enable volumetric analysis (of tumors, for example), and offer a “fly through” capability for hollow organs and vessels. As you will see in the article, the images can be projected on a wall-size (8×12 feet) screen, a surgical table-sized screen, a tablet (e.g., iPad), or a smartphone. A physician team can analyze the visualizations from all angles since 360 degree viewing is supported. The CAVE can become a surgical “pre-flight” simulator where the information on the screen is for the patient with a confirmed diagnosis for which operative maneuvers are being evaluated and planned. Clearly, treatment planning and the surgery, itself, might well be improved using this technology.  The implications for training surgery residents, as well as for maintaining and further developing the skill levels of fully trained surgeons are obvious.

But, the clinical benefits of visualization are not limited to surgeons and surgical patients. E. Brian Butler, MD, the physician who supported realization of the initial visualization technology in Houston, has a long-seated interest in image-guided intervention for radiation oncology patients.  He wanted to initially explore whether therapeutic agents were reaching their targets and doing what they were expected to do.  Visualization satisfies those goals while opening the door to new research and clinical opportunities.

Readers who seek out the full article (the MDVC Journal is on the web) will be surprised not only by what they see but also by the fact that this Black Swan hasn’t migrated to other important medical environments.  Why hasn’t it taken wing?

—James E. Lewis, Ph.D., is an independent consultant to departments and schools of medicine, teaching hospitals, cardiovascular and cancer research and clinical programs, medical professional associations, disease oriented foundations, consulting firms, pharmaceutical companies, components of the National Institutes of Health, the Centers for Communicable Diseases, and the predecessors of the Center for Medicare and Medicaid Services. Previously he served as Deputy Dean for Operations and Vice President for Academic Administration, The Mount Sinai School of Medicine and Medical Center, New York City, where his academic title was Professor of Medicine and Health Policy; and Senior Executive Officer, Department of Medicine, University of Alabama at Birmingham, where his academic titles were Professor of Medicine and Adjunct Professor of Sociology. He can be reached at Keep an eye out for his new Wing of Zock column, “Patterns”, coming soon.