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Preprints & Reprints VISIONS OF A PERFECT DIAGNOSIS Throughout my life it has always seemed that the very best of teachers have been able to put themselves in my place, assume my level of ignorance, and impart their understanding in a very graphic and enthusiastic way. Unfortunately, with the speed up of technological development, and subsequent broadening of the curriculum, the masters of this communication process are becoming all too rare across the breadth of education. To some extent the hard sciences overcome this through the use of mathematical and physical models that rapidly convey a mental image of a given process. However, in the soft sciences, and medicine is largely a soft science, the process is far more difficult. There is nothing quite like touching, feeling, seeing, hearing, smelling and tasting. Today?s students are faced with a bewildering repertoire of problems, diagnostic and remedial techniques. At the same time patient demand is increasing, human resource and financial budgets are constrained, all of which is promoting the need for the quick fix and rapid turn around. Like other sectors of industry, commerce and education, medicine is under increasing pressure to become more efficient. A fundamental constraint to medical students gaining sufficient practical experience is the limited access to patients. Just how many people can physically crowd around one patient to witness and/or participate in an examination or operation? At best only a handful! The use of commercial TV cameras and screens provides a partial solution, but lacks depth of vision and reality. However, miniature cameras are now the size of a shirt button and can be mounted on a spectacle frame worn by a consultant as he operates. The visual scene could then be transmitted to a multiplicity of sites where students equipped with Virtual Reality (VR) displays can observe and learn. These displays position miniature TV screens over each eye so that the students experience the event in 3D colour, with binocular depth of vision. A further refinement would see miniature microphones on the consultant?s head mount providing stereophonic hi-fi sound for the observers. This would increase the sense of realism and allow the remote students to hear the commentary by the consultant, and the interchanges with his operating staff throughout the process. Such a ?surrogate head? concept might appear far fetched, but in fact the technology is already at an experimental stage, with miniature cameras and VR displays available in small production quantities. Perhaps most importantly, the digital network that is vital to providing such a service is available throughout the UK and several European nations as well as many locations in North America. The Integrated Services Digital Network (ISDN) provides a dial up service as available and simple to operate as a standard telephone. So the key components for the realisation of instant, on demand sight and sound telepresence, are available now. The next tractable objective is to transport the tactile sensation felt by the consultant. However, this technology is at a much earlier stage of development and currently employs piezo transducers mounted on gloves at approximately 2mm spacing - which is close to the spacing of our finger tip nerve endings. The pressure on the consultants fingers could be transmitted over the ISDN to a reciprocal glove worn by a student. Here pneumatic bubbles in the glove replicate the sensation of pressure. Beyond this, the addition of an exoskeleton (or prosthetic) would allow the transmission of the forces on the fingers and arm of the consultant. Whilst most of the elements of this concept are in existence, they are bulky and uncomfortable to wear, and unlike a headset, are a great encumbrance. It will probably be another decade before a suitable solution is realised, but the prospect is a tantalising one. It is clear that the development of such techniques could see the rapid introduction of broadcast services to a large number of medical personnel world wide. The surrogation roles could also be reversed. When a clinician has perfected a technique and people have been teleported to see what he sees, hear what he hears, and feel what he feels, they could then attempt the same operation. Here the role reversal would see the expert sitting behind the eyes of the trainee, guiding him through commentary, sight and feel. Training in the traditional (and restricted!) sense will then be obsolete. This will also bring about a dramatic reduction in the time to disseminate information and experience, which in turn will impact significantly on our established means of publishing work. Logical extensions to these developments include robotic and remote surgery. Early trials have seen robots operating under autonomous control, programmed to remove tumours whilst being steered by a tomographic scanner. They exhibit an ability to achieve far higher levels of accuracy and reliability than the human surgeon and are now being introduced into retinal and joint replacement surgery. However, there remain many areas where human skill is extremely difficult to supplant and here we might contemplate the extension of our senses into robotic assemblies for laparoscopy, endoscopy and similar techniques. Trials have already shown that the addition of 3D vision and force (i.e., tactile) feedback from electronically linked controls and manipulators provides a satisfactory and workable solution. The next obvious stage is to teleport the entire human consciousness to a robotic platform so small that it can be inside the human body, or so large that it can replicate the presence of another human on the outside looking in. Whilst this might seem like science fiction, all of the base technologies are to hand. Why then has this not been done? On the technological side it is probably because of the perfection of such key areas as robotic manipulators, sensory systems and telecommunications has not occurred simultaneously. On the ethical side major changes in medical culture and thinking are required. All are required to force change, however realising the dream should take no more than fifteen years. Electronics has seen a doubling of computer power every year since 1960, and so the PC on your desk can be expected to be 1000 times more powerful within a decade and million times more powerful within two. Artificial Intelligence (AI) systems are now available for applications in finance through to drug administration and decision support for military and commerce. In medicine we can look forward to AI systems that seek out and gather the very latest information, correlate symptom, cause, diagnostic accuracy, and treatment, and thereby provide a new tool for the rapid identification and treatment of problems. Interestingly, many patients prefer to talk to a computer when divulging details of their ailment rather than relating directly to a doctor. They also tend to ve more candid, which facilitates more information being obtained and of greater accuracy. In addition, trials are already being conducted with electronic monitoring systems attached to patients to record the affect of drug dosage and analyse the efficacy of a treatment. The systems currently restrict patients to the hospital ward, but technological advances are certain to extend this to the home and place of work, with remote surveillance by the hospital computer and some treatments being administered remotely. VR is generally thought of as a games environment, but in fact it offers a plethora of new medical possibilities. For example, it is now possible to reconstruct tissue and bone that has been damaged by accident or some disorder with virtual operations in virtual space. In the case of a crash victim with facial injuries it is feasible to scan photographic information into a computer and construct a 3D virtual image of the face, and then the surgeon can peel back the virtual tissue, reposition bone and reconstruct many times until he gets a good facsimile of the original face. He may have to persist through 20 or 30 attempts to achieve a satisfactory result, but when this point is reached he is then in a position to retire to the operating theatre and get it right first time. Patient trauma and the build up of scar tissue is reduced, the tying up of valuable resource is negated and the surgeon has the potential of realising a better result in a shorter time. This technology is in its infancy but from practical trials it is clear that it does work and merely requires refining before being deployed to medical establishments throughout the world. Again telecommunications plays a vital role in this in the form of wideband communications links between the research and application institutes. The potential for surgeons to perfect their craft in VR space is obvious and probably on a par with pilot training, where more flying hours are now being clocked up than in real planes! As we move into the 21st century we can look forward to a world where the global sharing of information and ability will become the norm through telecommunications linking centres of need and expertise. Research will become more focused through the rapid dissemination and application of new and beneficial methods. In addition, entirely new ways of educating and training new entrants and those already established in the profession will be promoted. Most importantly, it is probably the only way of balancing the conflicting demands of rapidly growing patient numbers and expectation, with an expanding technology base and a student curriculum which has a fixed internship. It is also likely to see the wide spread deployment of many techniques and technologies that are currently centralised in large regional hospitals. The future GP may see a time when a consultant and complex facilities are available to him any time, any where, not just in the surgery but in the patents' home or the site of an accident via a ubiquitous digital telecommunications network. |