Alon Harris is an assistant professor in the Departments of Ophthalmology and Physiology and Biophysics at the School of Medicine. He is the director of the Glaucoma Research Laboratory, where he utilizes noninvasive techniques to study blood flow in the human eye. Dr. Harris is the principal investigator for a five-year National Institutes of Health grant to investigate ocular vascular regulation.
Doug Horner is an assistant professor of optometry, Indiana University Bloomington. His research is focused on understanding the shape of the
human cornea and how it can be modified to reduce or eliminate myopia.
Bill Tierney is a professor of medicine in the Section of General and Internal Medicine at the School of Medicine. He is a senior investigator at the Regenstrief Institute for Health Care.
Chuck Watson is a professor of speech and hearing sciences with a secondary appointment in psychology, Indiana University Bloomington. His current research focuses on the discrimination of complex sounds, including those of speech, and on the development of computer-based speech training systems.
David A. Williams is an associate professor of pediatrics and medical and molecular genetics and Kipp Investigator of Pediatrics. He is an associate investigator with the Howard Hughes Medical Institute at the Herman B Wells Center for Pediatric Research at
the School of Medicine. Professor Williams' interests include clinical aspects of pediatric hematology, experimental hematopoiesis, and genetic modification of hematopoietic stem cells.
Moderator: Mark Buechler
RCA: First, I'd like to hear what kind of technology you are using in your research and teaching. Dr. Horner?
Horner: I use technology in several ways in my research on the human eye. My largest investment is in the area of measuring the entire corneal surface
of the eye. I have several PC-based data acquisition devices commonly called video keratoscopes, which give us about a 5,000-pixel representation of the cornea.
My main role in the realm of technology and teaching is not so much with students but as a facilitator for our faculty. We are attempting to embrace photo CD, HyperCard software, multimedia, and other database software to build clinical simulations, tutorials, and generally aid instruction.
Garetto: Our Biomechanics and Biomaterials Research Center here at IUPUI has purchased an acoustic microscope that uses sound waves to image materials. We also use advanced mechanical testing systems for evaluation of biological materials. With these systems, you can do material and mechanical testing in a non-destructive fashion, so you can get properties of tissue without breaking it. Additionally, we are using finite element modeling techniques--which were developed for nonbiological applications like aircraft- -on biological tissues, to help us determine whether or not to do experiments in vivo (on living beings).
Finally, we are using the Space Shuttle to try and understand osteoblast differentiation in an environment without gravity (an osteoblast is a cell that forms bone). We've had experiments on three flights on the shuttle over the last couple of years.
Harris: My research on blood flow in the human eye uses cutting-edge technologies to assess the eye's circulation in entirely noninvasive ways. Only a decade ago, research in ocular circulation was performed almost entirely in animals using invasive methods which generally required the death of the animal. This not only represented a cost in lost animals, but also limited the applicability of the results to human diseases.
With the advent of digital laser scanning and color Doppler imaging techniques, we have been able to perform groundbreaking research on these and other diseases in human subjects for the first time.
Watson: My research lab acquired its first computer in 1968, and we have been increasing our computing power for research ever since. I've used this and other technology for a variety of research purposes: creating complex sounds for the study of auditory perception; measuring brain-wave responses to sounds; reaction-time measurements; video displays for lipreading studies; computers for statistical analyses, modeling, and graphical displays; and computer-based speech recognition.
As a spinoff of our research we developed a system called the Indiana Speech Training Aid to help deaf and articulation-disordered children learn to speak intelligibly. This system is commercially marketed now, and so we find ourselves to be entrepeneurs, as well as academic researchers.
Williams: Our laboratory effort includes an increasing use of molecular technology, including cloning, transgenic mice technology, bone-marrow transplantation and cell-culture technology, and homologous DNA recombinant technology. These technologies have become essential to current research efforts, which focus on understanding genetic mutations, gene regulation, and cell/cell interactions involved with blood formation.
Technology is also increasingly used in our teaching. We now routinely use videos to teach and critique different aspects of patient care and laboratory techniques.
Tierney: The focus of both my research and teaching is the computer medical records system. The one we are currently using was invented here. It's the broadest and most well-researched medical records system in the world. It has culminated in an electronic interface for the physicians and the nurses, who no longer use paper charts--which was 1800s technology--to communicate. In most of the country that's the communication medium in medicine: paper. Computers are doing laboratory tests and CT scans and things like that, but they end up printing a paper report, which goes in a paper chart.
The physician workstation I'm talking about is more than just an electronic rendering of a paper chart. Our system not only allows doctors to write orders, but sends the orders where they ought to go rather than having to hand-carry them. Drug orders go to a pharmacy, X-ray orders go to X-ray, and so forth.
The system can also check those orders and make sure physicians aren't doing dumb things. If you write an order for penicillin and the patient was in the emergency room ten years ago with an allergic reaction to penicillin, the system knows that even if you don't.
And it will tell you.
The system also has a link to the database where patients' records are stored, so you can get past X-ray results, past medications, things like that. It actually displays cardiograms on-screen, and soon it will be able to display X-rays as well.
Finally, we have access to information systems. For example, we can get the campuswide CD-ROM MEDLINE system to be able to search the medical literature.
Williams: I have an interesting footnote to MEDLINE. I recently saw a child with a very rare disease. This child was also seeing our geneticist here at IU, and after the child went home, I did a literature search and came up with one recorded case like this in the literature 10 years ago. And it was actually recorded by the same IU geneticist who saw the child, and he had not remembered the case. It shows you how useful that system can be.
Tierney: We studied the medical records system in a sixteen-month controlled trial. Half our doctors used it and half didn't. The patients of doctors who used it were hospitalized a day less and had hospital bills $900 lower than the doctors who didn't use it, and there was no difference in the quality of the care. So it looks like it makes the care more efficient.
Technology has also changed the way we teach students. We used to teach memorization, and you made diagnoses by remembering patterns. Now we recognize that you can no longer memorize enough to be a good physician. So we're teaching physicians of tomorrow not to memorize medicine but to learn how to access different sources of information in an efficient way to make decisions.
Garetto: As a matter of fact, we started teaching problem-based learning to our physiology students yesterday. We started with a particular disease with particular symptoms, and today they're all at the library trying to figure out how to look up information. This is the first year in which freshmen are having to do that. To a lot of them it's a new approach.
Williams: So far, all the talk has been about computerization. Another technology that is revolutionizing medicine is DNA technology. What you hear about a lot is the Human Genome Project and actually sequencing the whole human genome and how that's going to bring about new understanding of many diseases. But the part of the technology I find even more fascinating is that we now have the ability to target a specific sequence and make a model of the human disease in an animal. For instance, in our lab, in collaboration with Dr. Mary Dinauer [associate professor of medical and molecular genetics and pediatrics, School of Medicine], we recently made a mouse model of a childhood disease called chronic granulomatous disease (CGD) by knowing the gene structure, going into the mouse genome, mutating that gene artificially, and then creating a mouse with the disease from that germ cell. So now we can study an animal model of this disease.
RCA: Is there any danger in this, giving animals diseases they've never had before?
Williams: I guess there's always some risk that a mouse could get out and create a mutation in a wild group of mice. That's why we have very strict recombinant DNA guidelines and very strict animal care guidelines to abide by. So I think the risk, given the restrictions we work under, is relatively small.
RCA: Dr. Harris, you mentioned earlier that previously you used animals for research and teaching and now you do it on computers?
Harris: For example, we used dogs in physiology experiments to teach cardiovascular function, and the dogs would be sacrificed at the end of the experiment. But we now teach a lot of this through computer simulation. The pluses of this are that we no longer need to sacrifice these animals and we can deliver the teaching material at the student's rate.
But one main drawback is that medical students are no longer dealing with live organisms. It influenced me a lot, when I was a student, to deal with that real live dog. So I wonder if we are not missing something essential in educating them using technology. I wonder if the technology is not creating a distance between the students and the projects that they're studying, and maybe between us and the students.
Williams: And distance, if you're not careful, between physicians and their patients.
Horner: Well, I'm not sure that the distance is growing between us and the students. I like my projected new role of supporting them while they go through the materials. I like the idea of putting primary knowledge in the realm of the technology and then allowing me to deal with difficult or novel issues that haven't made it into that database yet.
Watson: I find that it's actually more efficient to communicate with a medium to large undergraduate class by e-mail (as a supplement to the lectures). I tell them, not only will I answer you if you ask me a question, but I'll give you extra credit if you ask a really good question. The question rate goes up. They get involved. There's a personal relationship that develops beyond what I can establish strictly through office hours.
Tierney: As far as physicians and their patients go, expectations have risen to the point where the more technology you use, the better. Patients like that, the doctors like that, everybody likes that except the people who are paying for it. People are afraid to make decisions without having measured everything first. So you'll see people coming to the hospital and getting thousands of dollars in test work without a physical exam, without somebody actually laying their hands on the patient saying, "Are you OK?" or "You have this and we don't need that." And the result is a health care system that cost $800 billion last year and is bankrupting the country.
Williams: This is a very important point and yet in most health care reform discussions I don't hear very much about it. People need to understand that there's a limited number of resources, and they are going to have to make decisions like this.
Tierney: Eventually we will. We're at the stage where we can do almost anything with the diseases that we can manipulate, and we now have to draw back and say, "Where is it appropriate to point this technology and where not appropriate?" Technology--expensive technology and inappropriate use of technology--has come down to a very moral/ethical viewpoint of what we do for whom and when.
Garetto: It's moral, ethical, and legal. Because people that aren't doing some of these things are the people that get dragged into court later on.
Harris: Another ethical issue may be accepting too easily that these technologies, because they're there and they seem impressive, are ready to be used. But a lot of them are really not ready to be used for diagnostic purposes. The color Doppler imaging that I mentioned earlier provides some very beautiful images, and it also provides some numbers for blood flow in the eyes, which is something that was very difficult to obtain before. Now, I've noticed that many ophthalmologists around the country are using this technology partly as an extra tool for diagnosis (and also for billing). But the problem with new technology like this is that it's still at the experimental level. We still have so much to figure out in terms of its sensitivity and its specificity, and so forth. Until we have gone through that phase, we shouldn't use it for diagnosis.
Watson: We've all had the experience of going into some labs around the country where they're so proud of the particular technology they're using, that's all they want to show you.Then there are other labs that want to show you their results. Now they also may be using the most recent technology, but they're clearly focused on what they're learning, not on "Look how I'm using this wonderful new supercomputer." Technology shouldn't become an end in itself.
Horner: I'm always deflecting some of my students away from a fascination with which mousetrap is better. A lot of them think that they're doing projects that are quite robust, but what they're really doing is comparing one apparatus against the other. They've tended to lose sight of the whole reason for this, which is to learn more about the visual system.
Tierney: Another problem with the use of technology in medicine is that information can obscure as much as it can enlighten. For example, soon we're going to have a noninvasive test for finding coronary atherosclerosis, and we're going to find a bunch of people out there with a fifty percent lesion in one artery. What are we going to do with that information? It's not going to help us care for the patients, and it's going to worry a lot of people. If I knew I had one of those, I'd probably stop running, I'd probably--I don't know what I'd do. It would drive me crazy.
Harris: Indeed, sometimes I fear that technology is driving research rather than the other way around. I have to stop myself and say, "Where am I going, what questions do I really want to answer?" Sometimes I think we ask questions and we seek help with technology. But when we get help from technology we find ourselves many times being dragged with the technology to directions we didn't think we'd be taking.
Tierney: When you've got a new hammer, everything looks like a nail.
Garetto: On the other hand, the technology can allow you to do things that you couldn't do otherwise. For example, the acoustic microscope that I mentioned earlier not only gives you an image, but provides mechanical and material properties at the cell level. So you can evaluate the material property of bone, or new bone adjacent to old bone, or bone formed during treatment with a drug that is adjacent to untreated bone. We couldn't do that unless we had this particular piece of equipment.
Watson: Can I just make one other general comment before we go? My interaction with engineers over the years has been extremely productive. I think engineers and scientists make wonderful teams. The fact that we can't have any engineering on the IU Bloomington campus reflects an anachronistic view of the relationship between engineering and science and a serious impediment to the quality of the work we're able to do.
Garetto: I think we could spend two hours talking about that.
Harris: The good news is that there are intercampus grants between campuses in the IU system. If you want to work with an engineer or clinician, for example, these are fantastic grants to obtain, and they help maintain connections between campuses.
Horner: One other thing that would have been interesting for this group to talk about is distance learning. Since we have essentially mandated continuing education for professionals in my field, one of my goals is to embrace distance learning in all its possible permutations.
Now, many practitioners/scientists will still want to attend some out-of-town seminars, because they might enjoy going to a particular location or something like that, but many people would like to stay in their office and still be able to get their required continuing education.
RCA: Are you developing any of this yourselves?
Horner: Yes, we're trying. Certain generic packages are already available, but the kinds of interactive models that we have in mind for the office environment aren't really there yet, and it's something we're trying to build on our own.
RCA: Well, in five years or so we'll get this panel together again and see how things are going.
Harris: You won't get us together. We'll all be sitting in our offices and doing it from there.