Fleeting moments

In the following blog, I will speak in a self-aggrandizing way. I apologize for this. It is not the nature of Canadians to be this way. Also, it really is not my personal style, for the simple reason that there is always someone much smarter and more capable in the room. For this blog, my boasting is necessary to make key points. I ask for your indulgence and forgiveness, and welcome any comments you may have.

At a young age, I already realized that I was far from the smartest guy in the room. I don’t know if it’s luck, a character trait I worked on, or those funny mushrooms I once tasted, but I’ve never felt the need to be the smartest guy in the room and/or recognized for my accomplishments.

I graduated in the top 10% of my bachelors degree even while doing, effectively, a double major. I graduated in the top 10% of my medical school class. Considering that McGill University is from the top medical schools in the world, that is legitimately an achievement. I didn’t bother going to my medical school graduation because there was a really good movie on TV. I placed second in all of Canada on an exam given to all surgical residents across the country. When I was told about this, I wrote to the examining board and suggested that they recheck their numbers, because I simply wasn’t that bright.

I have met a great many people in my life who have been desperate to be publicly recognized for any accomplishment. They are usually very small people, in terms of their hearts and soul, and I simply pity them.

Once I met  Dr. David Appelbaum, I felt that I had found my purpose. This is not a common thing. There are not many people in this world who can say that they found their purpose in life. But once I met David, I could see my future. I was going to be David’s silent lieutenant. Over the course of the decades that we would work together, I was going to be the guy that David called to get something done. No one would know my name, and I wanted it that way. I wanted to live as long as David would, so that I could always be there to help him make the difference that he could, in the world of medicine.

When David and his oldest daughter were killed in a terror attack well over a decade ago, my heart hurt for his family, and for the cruelty of his daughter dying the night before her wedding. But selfishly, I hurt for myself. I was lost. Meeting David was a defining point in my life, as it made the world make sense to me. But his murder, left me with questions that broke my soul. Just as an aside, I have never danced at a wedding or other joyous event since David was murdered. I decided that until I heard the reason for his murder, and accepted it, the dancing would wait.

In the aftermath of his murder, there was another orphan — TEREM. For those who do not know, TEREM is a medical services company that opens and runs community-based emergency rooms across Israel. The concept is simple — any emergency condition that does not require the full resources of the hospital, can be treated in the community. There are hard statistics from the Israeli health ministry proving the tremendous success of this model of medical care. After David was killed, I personally assumed two roles — assistant medical director and head of IT for all of TEREM. In the 11 years that would follow, I developed  a unique style of electronic medical record. Because of my dual background in computer science and medicine, I was able to translate the needs of doctors into the language of the computer. For those who have experience with this, you know how difficult a task this is. Over years of constant improvement and updates, I achieved an EMR that was considered by the overwhelming majority of its users (and senior Microsoft members) as a critical and helpful tool in the management of patients.

Long before major EMR companies in the US were talking about computer interfaces geared towards the clinical needs of doctors [versus the administrative needs of bean counters], it was already clear to me that a computer interface for an EMR would have to be incredibly streamlined for the doctors and all other users. It would have to be free of any distracting elements that were not directly related to the welfare of the patient. It was also immediately clear to me that doctors should never have to spend time looking for information. A properly designed EMR would always make the information necessary clearly available. My EMR was from the first in the world that totally integrated an x-ray viewing system. In this way, whether being viewed in a clinic or remotely via the Internet, a physician would immediately see a complete record of everything about the patient from one single interface. The amount of time that this saved and the number of errors that this prevented are countless. And I am proud of this accomplishment.

My EMR was also from the first in the world that integrated clinical assist tools. The purpose of these tools was to guide medical staff in ordering the necessary tests, remembering to check all pertinent clinical entities and most of all, to avoid basic errors in management.

During most of these development years, I had the assistance of a brilliant young woman who, amongst many other things, developed a data warehouse, which consolidated the data from all of the clinics into one source. She took a primitive model that I had designed for querying this data from the data warehouse, and turned it into a powerhouse of data analysis. It is the combination of all of these tools that made it possible for TEREM to be a very prolific generator of original research, even though we were not an academic facility.

Using the software I wrote, I built protocols and standards for health care which were implemented back in all the clinics. I could give you a long list of improvements in health care that I succeeded in implementing using my own system. As successful as this approach was, I am sad until today that David never saw it. He would have loved it more than anyone, for it would’ve given him the ability to provide care at a level that many others dream about.

I am constantly perusing the Internet looking for important stories in the medical field, computer science field, and most importantly to me, in the combination. I came across a TED talk, given by a gentleman by the name of Jeremy Howard, who is the CEO of a company called Enlitic. Jeremy and his associates are a group of people who very much make me the dumbest person in the room. I listened to Jeremy’s talk about deep learning, a technology for computers to learn on their own in a pattern-based way, that is superior to anything that predates it. I contacted his team and offered any help that we could provide from a medical perspective. I initially thought that this new deep learning system could process the data in our data warehouse to help us make better clinical decisions. Jeremy’s team were more interested in beginning with image analysis. At that moment, I realized that this was very possibly another defining point in my life. I told Jeremy’s team about our collection of x-rays and our ability to deliver a package of tens of thousands of films with supporting descriptive [or meta-] data.

My initial hope was that this deep learning system could identify fractures. It is astounding how difficult this can be at times and how often fractures can be missed. I suggested that we start with an anatomically simpler system,  namely the part of the forearm adjacent to the wrist, and thus began the first exploration into using a computer to rule out fractures in human bones.

This 1-minute video clip shows Jeremy Howard speaking at a conference called Exponential Medicine. This conference is arguably one of the top conferences in the world that deals with cutting edge medical technology. It is at this conference, that Jeremy decided to demonstrate the success of deep learning by displaying an example of the automated x-ray reading system that I described above.

As I looked at the image of the automatically identified fracture, I cried. I was part of something that would grow far beyond me and influence the quality of care around the world. I made a difference. I don’t know what greater reward there is in medicine.

What’s the next step? I have to tread very carefully at this point. I cannot name names, even hint at the role or relationship to me or occupation of the people I am about to refer to, for obvious legal reasons. Suffice it to say the following: for me, there probably will not be a next step. Selfishness, small-mindedness, greediness, and a general but fundamental lack of ethics and morality have stopped me in my tracks. There are people who value their own reputations and definitely their own bank accounts, high above the general welfare of the public. There are people who would actively interfere with the tremendous potential of certain research, due to their own pettiness and soulessness. These are the people who are doing everything in their power to make sure that my personal role in advancing such research has ended.

There are other people who support my cause. The problem is that support can be totally ineffective. In this particular case, the kind of support that is necessary is one where the powers that block me are challenged so aggressively and so assertively that they have no choice but to back down. There is such a thing as “not taking no for an answer”. But this is hard to do. Sometimes, people who refuse to accept a negative response, lose money, their job, their standing in the community and even more. Every person has to decide for themselves what the red line is. Every person has to decide at what point you refuse to kneel.

When people look around and ask “why are things so bad”,  the first thing they should really do is look in the mirror. The first thing we should do is ask ourselves — how hard did we fight against the injustice in front of us? Were we willing to sacrifice enough to guarantee the righteous way? It is, of course, everyone’s prerogative to walk away from such complicated situations. But when people are swept up in the chaos of injustice, rather than scream to G-d, they should first look inward and question their own soul.

This kind of work that I have had the great luck of being involved in, is not about becoming known or making money. On the other hand, this kind of work makes a difference. This kind of work is worth fighting for, and I have already lost a great deal fighting for this project.

On this day when I should be so happy, I am very sad.

Thanks for listening.

About the Author
Dr. Nahum Kovalski received his bachelor's of science in computer science and his medical degree in Canada. He came to Israel in 1991 and married his wife of 22 years in 1992. He has 3 amazing children and has lived in Jerusalem since making Aliyah. Dr. Kovalski was with TEREM Emergency Medical Services for 21 years until June of 2014, and is now a private consultant on medicine and technology.
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