Sustainable Capacity Building for Utilization of Advancements in

Medical Technology

DR ABIODUN D. OLUSESI, FWACS, FMCORL•SENIOR CONSULTANT EAR, NOSE, & THROAT SURGEON

NATIONAL HOSPITAL, ABUJA•CEO, CSR OTOLOGICS INC. ABUJA

-THE ROLE OF RESIDENT DOCTORS

"It must be realized that there is nothing more difficult to plan, more uncertain of success, or more dangerous to manage than the establishment of a new order of things; for he who introduces it makes enemies of all those who derived advantage from the old order and finds but lukewarm defenders among those who stand to gain from the new one"

- Niccolo Machiavelli

OUTLINE•DEFINITIONS•CONCEPT OF MEDICAL TECHNOLOGY•GROWTH OF MEDICAL TECHNOLOGY / FACTORS / VARIABLES•TYPES OF NEW MEDICAL TECHNOLOGY / ADVANCES•ROLE OF RESIDENT DOCTORS: UTILIZATION Vs IMMERSION•RESIDENT DOCTORS & FUTURE MEDICAL TECHNOLOGY ADVANCES

Preamble: Resident Doctors

•Residency is a stage of graduate medical training•may follow the internship year or include the internship year as the first year of residency•can also be followed by a fellowship, during which the physician is trained in a sub-specialty•Successful completion of residency training is a requirement to practice medicine in many jurisdictions

Preamble: Residency•as an opportunity for advanced training in a medical or surgical specialty evolved in the late 19th century from brief and less formal programs for extra training in a special area of interest•became formalized and institutionalized for the principal specialties in the early 20th century•Residencies are traditionally hospital-based and in the middle of the twentieth century, residents would often live in hospital-supplied housing

Whereas medical school teaches physicians a broad range of medical knowledge, basic

clinical skills, and limited experience practicing medicine, medical residency gives in-depth training within a specific

branch of medicine

Medical treatment is a two step process.

•First, the physician must diagnose a disease, and next•The physician must decide the course of treatment given the disease the patient is assigned

Preamble: Medical Technology

•Procedures, Equipments & Processes by which medical care is delivered•Could be

•New medical procedures (CI, Angioplasty, face transplant)•New devices (fMRI, PET, HRCT, HRMRI)•New support system (EMR, Telemedicine)

Preamble: Medical Technology

•No area of medicine unaffected by advances in medical technology•Technology is a continuous piston of bearing that works on the principle of auto evolution

Medicine / Medical Technology Auto evolution

Old Medicin

especialtie

s

Subspecilties

Preamble: Sustainability

•Capacity to endure•Potential for long term maintenance of wellbeing•Sustainable indicators, metrics, benchmarks necessary to set goals

•I = PAT•WHERE I = environmental impact; P = population; A = affluence (level of consumption); and T = technology (impact per unit of resource)

•Innovative Capacity Building Vs Sustainable Capacity Building

•technology per se would be incapable of playing a major role in the achievement of sustainability or that technologies capable of delivering substantial resource productivity improvements are not, in principle, feasible•usual innovation processes and practices would not lead automatically to technologies compatible with sustainable development

Challenges of sustainability

•The need for factor-10 to factor-50 improvement is implied•This challenge to be far beyond the range of improvement possible through end-of-pipe technologies and even most 'environmental' technologies, which represent process-integrated improvements to the ecoefficiency of current processes and products.•To have any chance of meeting the technological challenge of sustainability, it may be inadvisable to follow the traditional route of studying present products and processes as a way of identifying areas for improvement

This presentation is about thinking out-of-box on resident doctor's role on how to achieve

sustainable capacity building towards integration of

advancements in medical technology

What do we know?

If you cannot figure out 5 ways to abuse a tool, then

you do not know how to use it!

Evolution of Medical Technology•Hippocrates (460-377 B.C) and Galen (131-201 A.D):

first documentation of process of healing•Early 19th century: Hutchinson's device for measuring the vital capacity of the lungs. Another device is Herisson's sphygmomanometer for blood pressure measurement•1st half 20th Century: thermometer, stethoscope, microscope, ophthalmoscope, laryngoscope, and x-ray debut•2nd half of 20th century: more complex medical technology >> more specialist & subspecialists

Medical Technology of 20th Century

•Acceleration in knowledge and technique + improvement in public health•Technical

•New way of viewing the body and its cells•Antibiotics discovery•New vaccines•Computerization of research

•New Surgical Technique•Transplant & Keyhole surgeries•Genetic engineering

Leading 10 Medical Technology Advances of the 20th Century•1900 - 1910: Karl Landsteiner: ABO System (also ECG)•1911 - 1920: Madame Curie - X-ray (also ET)•1921 - 30: Sir Alexander Fleming: Penicillin (also Frederick Banting and Charles Best discover insulin)•1931 40: Henrik Dam � �Vit K (Also Debakey Pump)•1941 50: Cortisone, Vit �B12, Streptomycin

•1951 - 60: Dr. Joseph E. Murray, first kidney transplantation; Paul Zoll develops the first cardiac pacemaker (also Polio vaccine; coronary angio)•1961 - 70: Dr. Christian Neethling Barnard: First heart transplant (also artificial hearts)•1971 80: "CAT-scanner. � �(also PET scan, MRI scan)•1981 90: HBV vaccine (also �1st craniopagus twins separation)

Last decade / first decade

•2003 - Carlo Urbani, of Doctors without Borders alerted the World Health Organization to the threat of the SARS virus•2005 - Jean-Michel Dubernard performs the first partial face transplant•2006 - First HPV vaccine approved•2006 - Second rotavirus vaccine approved (first was withdrawn)•2008 - Laurent Lantieri performs the first full face transplant

Contrast Clinical Engineering Evolution: Important Timeline 20th Century Inventions•Electronic TV invented

1923 (Philo Farnsworth)•Electroencephalograph (EEG) 1929 (Hans Berger)•Xerography 1938 by Chester Carlson•Computer by Conrad Zuse in 1941•Medical Ultrasonography 1953•Integrated Circuit in 1958

•Thin film transistor 1961•Light Emitting diode 1962•Computed tomography 1972 (Hounsfiled & Cormack)•Artificial Heart (Robert Jarvic) 1982•Lithotripsy (1984) by Claude Domier•Polymerase Chain Reaction (PCR) 1985, Kary Mullis

Summary of Last 40 years of Medical Technology

As 20th century morphed into the 21st, Medical advances are aided mainly by the tripod of

•Mechanisation•Automation •Digitalisation

IT Systems in HealthCare

•IT systems only arrived in hospitals in the late 80s, today clinical and administrative processes are managed via a hospital information system (HIS), for which the clinical workstation is continuously evolving

•Mid-80s the first digital image archives (PACS), radiology information systems (RIS) and laboratory information systems arrived•1970s: immunofluorescent techniques for detecting auto-antibodies and infectious agents, and in the 1990s advances in molecular biology opened new diagnostic opportunities at the picomolar level

IT in Medical Technology

•information and communication technology has not only made possible automation in the clinical lab, but all kinds of hospital practices.•The first patient monitoring systems, which are now taken for granted in intensive care and neonatal unit, were introduced in operating rooms and wards in the mid-1960s. •In the clinical laboratory, computer development made possible large-scale diagnostic tests in the 1970s

Medicine & Technology: Interaction - RadioSurgery

•Gamma Knife•Uses high dose irradiation for single Rx of Brain cancers (e.g. VS, Vascular Tumours)•device aims gamma radiation through a target point in the patient's brain•ablative dose of radiation is thereby sent through the tumor in one treatment session, while surrounding brain tissues are relatively spared

•Cyber Knife•frameless robotic radiosurgery system•Deliver Targeted XRT to tissues•The 2 main elements are

•(1) the radiation produced from a small linear particle accelerator and •(2) a robotic arm which allows the energy to be directed at any part of the body from any direction

Gamma Knife Cyberknife

Medicine & Technology: Interaction - PET Scan / fMRI

PET Scan

•a nuclear medicine imaging technique •produces a 3-D image or picture of functional processes in the body•The system detects pairs of gamma rays emitted indirectly by a positron-emitting radionuclide (tracer), which is introduced into the body on a biologically active molecule•Use in tumor imaging in ORL

Functional MRI

•specialized MRI scan that measures the hemodynamic response (change in blood flow) related to neural activity in the brain or spinal cord•Principle known since 1890: changes in blood flow and blood oxygenation in the brain (collectively known as hemodynamics) are closely linked to neural activity•Use in CI Candidacy / Brain mapping / Neuro-surgical planning(oncology)

Brain blood flow with activity

PET ScanFunctional MRI

Medicine & Technology: Interaction - Neuronavigation

System•An offshoot of stereotactic surgery•Technology made possible by the advent of modern imaging techniques (CT, MRI) as well as ever increasing capabilities of digitalization, computer graphic modeling and accelerated manipulation of data through complex mathematical algorithms•Debuts in 1990s

•Neuronavigation = image guidance systems consisting of the following:

•a computer•a position sensor•a digital image of the surgical field in question this image is obtained �from CT scan and MRI scan

•Use in ORL for skull base tumor resections, nasal and sinonasal surgeries, and otological / neurotological procedures like mastoid surgery, petrous pyramid lesions, retrosigmoid approach to the cerebellopontine angle, middle fossa approach to CPA and resection of jugular foramen.

From Neuronavigation to Robotic Surgery-

Supervisory Controlled Robotic surgery

From Neuronavigation to Robotic Surgery: Tele-Surgical Robots

From Neuronavigation to Robotic Surgery- Shared Control

Robotic Surgery

Robotic Surgery Session - Theatre View

**Over 280 units of the Da Vinci System has been deployed worldwide

Factors Influencing Growth of Medical Technology

•Consumer demand for better health•Increase income; increase public awareness

•Efficient Health Insurance Systems•Desires by professionals•Level of investment in basic science & research•Commercial interests

•Pharmaceutical & medical equipment makers

Future Advances of Medical Technology

•Imaging•AFM

•Drug Delivery•Molecular robots (crude: Camera pills)

•Molecular Surgery•Nanotechnology

•Regeneration Medicine•Stem cells therapy•Genetic engineering

Future of Robotic Surgery

•a system which can perform a wide spectrum of surgical procedures, an increasing usage of telementoring and telesurgery, improvements in artificial intelligence, and virtual reality.•The future of surgical robotics will see robots with ambidextrous abilities, more degrees of freedom, kinesthetic feedback, and a more user-friendly interface2•Greater integration of artificial intelligence and nanotechnology will soon create surgical procedures that cannot be done without it, revolutionizing neurosurgical practice

Future Advances: What Role for Resident Doctors?

•Understand Technology•Utilize Technology•Be immersed in Technology•Think globally, and act locally

Open Quiz 1: Operating Room or A Radiological Investigation Room?

Medicine & Technology: Current Trend

Current trend is towards fusion of MRI, fMRI, Neuronavigation, High Resolution CT, and High Resolution ultrasound into a single imaging /

therapeutic tool for optimal patient care

Medicine & Technology: From the Present to

the Future•Brace up for

•Bigger roles for computers in the OR•Nanotechnology Applications to medicine•Molecular Imaging

Medicine & Technology: Because If You Do Not...

Victims of Medical Tourism Mis-adventure?

Failed Implants Failed Implant Surgery?

Sustainable Capacity Building Which Is the Best

Model?•Introduction of Medical Informatics into the curriculum of medical students / junior residents?•Enforcing use of medical technology for purpose of post graduate examinations?•Health ministry to establish / acquire / partner medical equipment companies?•Centralized Healthcare Control System for Nigeria?

Open Quiz 2: Identify your preference

•Will you prefer any of the following?•Take all or part of your fellowship examination online?•Buy an online only copy of a specialty medical text with no option to print?•Prefer to take your CME for MDCN annual registration via your mobile phone?•Go on strike if your hospital administrators deduct a sum from your pay to provide you with handheld computers / smartphones to effectively function as a resident?

From a US Medical School Survey: >1000 Med Students

•~90 percent - of students surveyed view the information available through mobile or online drug and disease references, such as Epocrates, as highly credible, second only to medical journals. Students also confess they are more than four times more likely to consult a mobile reference for a clinical question than ask their attending physician•The survey found 45 percent of respondents currently use an iPhone(TM) or iPod touch(TM), followed by Palm and Blackberry(TM)•Students also confess they are more than four times more likely to consult a mobile reference for a clinical question than ask their attending physician.

Ref: Future Physicians of America survey by Epocrates

Open Quiz 3: What is

•Capacity Building?•Assistance provided to some societies, organizations, etc especially in developing countries to enable them develop certain skill or competence?•An ongoing process through which societies, individuals, and organization enhance their abilities to meet developmental challenges?

-UNDP

Capacity Building entails

•Creation of enabling environments with appropriate policy and legal framework (ICT for D)•Institutional development, including community participation; and •Human Resources Development and strengthening of managerial systems

Sustainable Capacity Building in Immersion in Advances of Medical

Technology •Is a long term, continuing process•Requires all stakeholders: residents, trainers, professional associations (NMA, MDCAN, etc), hospital and university administrators, health ministry, NGOs and development partners to participate•In Nigeria context, requires establishment of Nigeria Medical Informatics Association (NMIA) to spearhead

So What do we do?•Equip user populations with both the capacity and the tool to implement medical technology and derive the associated benefits•Enrol the current NARD leadership in global informatics mentorship program•Establish a regulatory infrastructure to promote the Access and Use of Medical Technology•Develop interest in developing Nigerian Medical Device Directory (NMDD) regulatory body

•This should lay out basic requirement for medical device safety and performances

Lastly...

•NARD can partner with Association of Computer Science Students to enhance early appreciation of challenges in health care diagnosis and treatments (e.g of Schlondorf)•Alternative is to encourage CSS or Clinicians to take interests in medical informatics as a carrier, and expose such to global mentorship program early enough

The Future can be found at the point where

technologists receive specialist input, or where

specialists become imbued with technological knowhow