Combinatorial Creativity: Or why modulation was the epochal event in Radiation Oncology

Martin Vial writing on Medium:

There are three types of change that take place to create something new.

First off, we can engage in combinatory change: adding new elements together to bring about something new. The example I used in an earlier article is the addition of the electric motor to a washbasin to create a washing machine.

Second, we can bring about augmentative change: improving the elements so that, while retaining the same basic identity, they perform better. An example of this would be creating a new computer with a faster processor or a screen with more pixels; the element, in this case, a processor or screen, is fundamentally the same, but it has been improved upon.

Thirdly, we can engage in design change: this is neither improving upon the elements, nor adding new elements, but simply rearranging or reorganizing the existing elements. This is how a plate becomes a bowl, which is much easier to cut on because of its flatness.

This requires some understanding. If my memory serves me right, the forerunner of the modulation was the Peacock Nomos system with different components named after birds. The translational form of radiation therapy given (now as tomotherapy) was an improvement over the predecessor. As a gradual improvement over the 2D to 3D led to the mathematical formulation by Brahme in his earlier papers on modulation, leading to intensity modulation.

I think that transition from 3D to modulation was a complete game changer.

Combinatory change was 2D to 3D. Augmentative change was 3D to IMRT. The design change is further refinements in IMRT to other rotational formats.

The current MRI-LINAC is in the 2D space of the 90s and will completely revolutionise the access, especially for in-vivo imaging and real-time tumour tracking, without an additional expense of bombarding radiation. My submission is that the newer technology around IoT, in room 5G networks, and on-board GPU based super computational processes and algorithms will make radiation therapy more inclusive. We are in for exciting times.

Why did I choose an equivalent of design? I had been struggling with the ideation around defining these epochal moments and the impact of technology (and creativity). Technology advances because it is inherent in its nature. The advancements come with the expansion of marketable relatables to increase its value and make higher profits for the companies pushing the envelope. There’s not much to be made in IMRT systems than a VMAT delivery with DIBH. Even though, the dosimetric advantage is piffling. A lot depends on the algorithm, uncertainties and set up. These are not “cutting-edge techniques”, but refinement of what was working perfectly fine before. I call them solutions looking for clinical problems, and then using the weight of “academics” to stifle any arguments about their efficacy.

It also explains my quest to understand the design principles inherent in the EMR’s. Digitised medical records speed up transaction and are cheaper to maintain in the long-term, but extract significant damage on the end-user because they are not designed to be “user-friendly”. These friction points cause negativity around what is essentially reliable for us in the medical domain. Apple nailed the UI design and has stayed true to its roots;; even though I’d argue there has been no real innovation after the first model. We urgently need the iOS design principle to find its feet in the tools we operate to hide unnecessary complexity and speed up adoption.