AI/DL/ML win or fail?!

So, I recently received the following recommendations from Quora of topics / people to follow:

This merits some work to figure out what is going on here. Note the first recommendation to follow "Jewish Theology and Philosophy." Expected recommendation: I am Jewish and I 'follow' several other Jewish topics on Quora. The Ariel Sharon recommendation is, however, thought provoking. It is true that Ariel Sharon, deceased in 2014, was Jewish and was a leader of the State of Israel. Might be reasonable to suggest this recommendation based on my Judaism. Maybe Quora has access to some of my personal data (unlikely?) that shows I've been in Israel several times (I got married there). Quora says it is making the recommendation, "Because you follow Sharon, MA." At first glance, you might think this is an AI/DL/ML fail confusing the name of the person with the name of the town. I follow Sharon, MA because that is where I grew up. If you know a little more about Sharon, you know that it has (or had) a large Jewish population. It also has had a number of youth make various trips to Israel and a Jewish, Sharon teen was killed in Israel not too long ago. So, now, it's looking like the AI/DL/ML algorithm is really smart and has examined far more data that we would think. Or not. As we start to develop AI/DL/ML in medical and medical imaging contexts, we're going to run into similar situations where we are not quite sure if the AI/DL/ML is brilliant or a moron. Of course, we're all used to dealing with the 'idiot savant' resident who occasionally blurts out a brilliant answer. Interesting times ahead.

A Prayer for the Motorcyclist

Just got back from 2017 Ride 2 Remember. I thought that for next time, we might need a Mi Sheberach. I propose the following for general use...

מי שברך אבותינו, אברהם יצחק ויעקב, ואמותינו שרה, רבקה, רחל ולאה, הוא יברך את כל רוכבי סוס ברזל, את משפחתם, ואת מכונאיתם ואת כל  אשר להם.

הקדוש ברוך הוא ישמר ויציל אנשי שני או שלוש גלגלים מכל צרה וסכנה, מצמיגים שטוחים עד בורח מגז.

והוא יגו אותם ממָכָּ'ם וגשם, מגנבים ונהגי מיטה.

אנו מפצירים בו להעניק את רצונם לטיולים ארוכים ובטוחים, דרך אור שמש ומתפתלות המוליכים הביתה אל משפחותיהם האהובות.

ונאמר אמן.

May he who blessed our forefathers Abraham, Isaac and Jacob, and our foremothers Sarah, Rivka, Rachel and Leah bless all who ride the iron horse, their families and mechanics and all that is theirs.

May the Holy One, blessed be He watch over and save the people of two or three wheels from every trouble and danger from flat tires to running out of gas.

May he shield them from radar and rain, thieves and bad drivers.

We implore him to grant their wishes for long safe trips through sunshine and winding roads leading home to their beloved families.

And so, let us say, amen.

All feedback and grammatical corrections welcome. Keep the shiny side up.

Dave

A one-line, state legislative fix for at risk, state Obamacare exchanges

First, let us not shed a tear for the health insurers threatening to leave (or having recently left) unprofitable state health insurance exchanges. None of the top 5 (10?) health insurers in the United States (outside the federal government) failed to make a profit (or revenues in excess of expenses, for those not-for-profits) in their most recent fiscal year. Many (most?) have large reserves or endowments that would put many to shame. Admittedly, some are losing money on their exchange plans, but that is how the health insurance game is meant to be played whether in private or in public. The wealthy must subsidize the poor and the healthy the ill (and the young, the old). They could and should amortize any ACA losses across their other plans. So, I propose the following language to be put on the books of any state where ACA exchanges are at risk:
"Any entity underwriting health insurance of any kind in the great State of XX shall also offer at least one set of conforming medal (bronze, silver and gold) plans in the State of XX's health insurance exchange." In the unlikely event that all health insurance carriers leave the state, that's a great vote for a state-wide single payer plan which is where we should be anyway.

Hammering the final imaging interoperability nail.

  While the rest of the medical world suffers a lack of EMR interoperability because there is no standard for the export of complete patient information (!), we, in imaging, are hampered by more mundane matters. As has been true for the past 30-odd years, Medical Imaging is way ahead in the development of interoperability standards (DICOM) and technical frameworks (IHE).

  Intraoperability of imaging within an enterprise is very mature. Transferring images between providers and enterprises via a patient transported CDROM and its subsequent importation into the destination system has been available for decades. Technical frameworks for the direct, electronic interoperability of imaging studies across enterprises have existed for many years. There are ongoing, multi-institution, multi-vendor demonstrations of this interoperability.

  BUT, in the real world, outside the demonstration, commercial, direct, electronic image sharing across enterprises does not occur. None of the commercial medical image sharing vendors, large or small, federate with each other despite the fact that they may do so as part of the demonstration project. Shame on them. When we write checks to one another or otherwise transfer money, our individual banks are federated to each other and through clearing houses to make the transaction work. Similarly, when EMR systems place e-prescriptions, these transactions go through clearing houses to reach the pharmacy of your choice. If these institutions have identified the business model that facilitates these exchanges, then why haven't our vendors done similarly? As I have written before, this is because of market driven engineering. Vendors will only implement that for which their customers demand. So when you go out to subscribe to an image sharing vendor's service, insist on federated (IHE XDS-i.b) exchange. If only there were a national office to coordinate health care IT that could coordinate this nail into place.

Have we arrived at a single payer fork in the road?

    The recent articles about the DOJ's efforts to block the "merga-mergers" of Anthem / Cigna and Aetna / Humana prompt me to believe that the battle for a national, single payer is (almost) over and we (who support that notion) have won, and lost. Sort of. 

    The insurance companies have long realized that their endgame is a monopoly, toward which we hurl despite DOJ brakes. They know that they only need one room full of math geeks, math geeks, math geeks, and math geeks (who knew they had so many professional societies!) and one computer to compute actuarial risk for what is, from a health risk perspective, one pool, Americans. The rest of the differences in the thousand points of darkness that are individual health plans, wellness benefits and other meaningless fluff, used as bright shiny objects to confuse politicians, are artifacts of revenue optimization that are unnecessary in monopoly-hood.

    So, we will arrive at a single payer and it is here that we have two choices: Medicare-for-all (I know that, together, we can Kumbaya a better name) and ACAH-Megacorp (only because I heard from John Oliver that "Tronc" is taken). There are only two important differences between the two: salaries of the executives/bureaucrats that run them and what gets done with the 'revenues in excess of expenses' (since everyone thinks they're a non-profit these days). Anthem has cash reserves of $1.5B, Cigna $2.5B, Humana $2.5B, and Aetna $17B (who's gonna win that game?).

    Interestingly, the drug companies are well versed in the writing on the wall. They have long ago won the battle against Medicare since, by law, Medicare is the black knight in any drug related battle. They are now at war with ACAH-Megacorp.

    Now the AHA and AMA (doctors, not motorcyclists or model aircraft enthusiasts) find themselves in a pickle. AMA opposes the mergers (and presumably monopoly-dom), AMA opposes Medicare-for-all, AHA opposes mergers, AHA opposes Medicare-for-all. Who will be a harsher taskmaster? The cold cutting whip of  jackwelchian capitalism or the all measuring, all knowing, Earth mother? Better Medicare-for-all then Medicaid-for-all.

    And so, we come to the ultimate paradox. Unstoppable force meets immovable object. Capitalism versus Socialism. Do we want this single payer to be run by the capitalists or the socialists. I, for one, have frequently ranted that we want this payer to be run by the Socialists. Capitalism is great for many things such as cars, cell phones, computers and the like. We understand that not everyone can drive a Tesla Model S or pocket an iPhone[n+1]. Our society even tolerates that some people eat filet mignon, some eat pizza and fast food, some eat Ramen, some eat dog food and some children eat only once every day or two. That's a sad commentary on our society but true nonetheless (We still have a huge number of food pantries in the USA!). No one, however, is (nor should they be) willing to settle for anything but the Cadillac (so to speak) of health care. If everybody with Hep C wants Hervoni, to survive, isn't everyone with aging going to want the anti-aging pill when it is available? The young must subsidize the old, the healthy the ill and the wealthy the poor. There is no other way.  By its very nature, providing health care service is a human and humane effort, social by its very fabric. We, Americans, humans all, take care of each other. Who wouldn't bring some soup and medicine to a sick neighbor. Why do we shy away from institutionalizing this humanity? Solely because its name is Socialism.
   So, I vote, let's cut the crap and red tape and just go for the Medicare-for-all option. The quicker we get to this single payer, the quicker we can simplify the system. Let the Department of Health and Human Services  (read that name again, aloud) manage the program.

Sidebar: What was wrong with the Department of Health, Education and Welfare that I grew up with? What better things upon which to spend the wealth of a nation than on the health, education, and welfare of its people. For welfare is not an evil word. Welfare means, "the good fortune, health, happiness, prosperity, etc., of a person, group, or organization; well-being". Even in it's other sense, it still only means, "financial or other assistance to an individual or family from a city, state, or national government". Are we not about to enter a discussion about 'basic income' in light of the successful automation of our industries?

    Every one in health care would have to survive on Medicare rates: Providers, hospitals, medical device vendors, and the drug dealers. We would have to re-arm the black night (all puns intended). The socialist Medicare-for-all will still have to compete with touch points in the capitalist world. If we want the best and brightest to be our providers then we will have to value and compensate them appropriately, perhaps make medical school free.  If we want the best scanners and technology, the best drugs then we have to value them appropriately, but not without bounds. It is not a free market.
    But wait, with all those health insurance people displaced to sell life, auto and home insurance, the law of supply and demand will mean that the cost of those insurances will fall, too! (Oh, wait, I forgot, capitalism doesn't work there, either).  To abuse Ben Franklin's words, "We must all hang together or most assuredly, we shall all hang separately". Sure seems to apply to this crazy thing we call the American health care system.

"Extinction of the radiology report" or the radiologist ?!

  As I await my hand-tooled leather bound, numbered and signed copy of Curt Langlotz's book, The Radiology Report (Amazon), I am most intrigued by the next to last section of Chapter 12, "The Possible Extinction of the Radiology Report." I, myself, have been giving this a lot of thought in the context of the acquisition of Merge by IBM Watson Health. Their tag line for the acquisition, picked up immediately by the media is, "Watson to Gain the Ability to 'see' with Acquisition of Merge Healthcare."

  I do see (no pun intended)(OK, going forward, all puns intended) how this could be interpreted in several ways. Some will say that they acquired the legendary 'Merge DICOM Toolkit(tm)', one of the first and finest(?) DICOM SDKs in existence. So, in that sense, Watson can ingest, digest, and expel(?) (exgest? vomit?) medical images. (It is hard to stop anthropomorphizing Watson). But that has been easy to do for decades now. I would argue, as is my wont, that a DICOM toolkit is not truly 'seeing'. A DICOM toolkit is, to a robot or information system, perhaps, the 'retina' of the image seeing process; Transmitted 'energy' transformed into a representation that can be processed by the 'brain'. I may be going too far, here (bear with me, I'm getting to a point).
  I would continue to argue, as is also my wont, that computers do not see by ingesting data. Computers 'see' by algorithms. We are all familiar with some of those algorithms such as those that detect and classify breast calcification and masses. We are also all familiar with new niche CAD applications in development. IBM and Watson already surely have access to scads of laboratories working in this area. As I respond, however, to people who come up to me at cocktail parties (admittedly a rare occurrence; cocktail parties not people coming up to me) and say, "aren't you afraid of losing your job as a radiologist to a computer?",  "That ain't going to happen in my lifetime." So, for now, we can consider Watson a child, born blind, who is beginning to perceive the outside world and may just be able to recognize a few, very specific, objects.
  There are, then, probably some who think that Watson can 'see' because they acquired billions of images AND their associated radiology reports under management by Merge systems at thousands of Merge customers. What a tantalizing training set! Of course, a tremendous amount of image processing and manipulation to do as well as a ton of NLP (even if you created UIMA). Now, others, as is certainly their wont, will argue over who owns this field of haystacks. As many lawyers as can dance on the head of a pin could debate this, but I, and many others, would approach and say, "Your Honor, the patient owns their data." The health care providers are merely stewards, curators, users and librarians of the data, accessioning, analyzing and reporting to the patient. The Merges of the world are merely contracted file cabinet salesmen and managers. So, it is not inconceivable to imagine a horde of IBM lawyers (some of whom are aware of the impact of Watson to their own profession) descending on Merge customers to negotiate new Common Rule ways to approach their patients to ask them to donate (?!) their images and reports to the medical education of Watson.
  I don't see it that way at all. To my mind, Watson, through Merge, acquired 'desktop' software access to hundreds, if not thousands, of radiologists. To my mind, this is the most intriguing prospect and strikes to the core of what it means to be a radiologist. Ginni Rometty, herself, predicts, "every decision that mankind makes is going to be informed by a cognitive system like Watson." Broadly speaking, radiologists do five kinds of work, Clinical, Research, Education, Administration and Management (which explains why we are the CREAM of the crop). Make no mistake about it, though, what Radiologists are paid, generously, primarily to be is eye-brain systems: Make image feature observations and derive inferences therefrom. We are not better than other humans at finding Waldo, rather, "expertise in medical image perception is domain specific and dependent on the extensive training that radiologists receive in that domain."
  One chronic problem we have with information systems, in general, is that we still ask computers to do things at which they are not good when a human is better and available and we similarly continue to ask humans to do things at which they are not good when a computer is more suited to that task. That is the crux of the opportunity. We are very good at making those image observations, and slightly less good, I bet, at making the inferences but we are very bad at, for example, searching for patient information (even in a connected EMR) in a useful and efficient manner, knowing the entire patient context, and knowing all the myriad details of a broad list of gamuts.
  Watson, I would also bet, is very good at these latter tasks. I suspect, he is, or will be, a near perfect Bayesian. Through Explorys (another recent IBM acquisition) Watson will have access to a ton of "Data Related to the Delivery and Cost of Healthcare." Access to EMRs will not be far off. Through Phytel, (yup, another recent IBM acquisition), Watson will have access to population health data. Watson will know far more about the patient, diseases and disease management, and how that specific patient fits in to precise population metrics and experience far better than any human. And in a very Deep Blue-ish way, Watson will be able to find the most cost-effective path to the 'end game' for that specific patient. 

  Watson, however, also has needs. I believe the appropriate reference is Feed Me. Watson needs input, especially in imaging, from humans where the long arm of electronics cannot yet reach. So, if I were among Watson's keepers, I would be adding structured image annotation to Merge's workstation software as fast as humanly possible. The good news is that a surprisingly good looking group of researchers were funded several years ago by the NIH NCI AIM Resources to develop a 'standard' information model and tools to represent structured biomedical image annotation and markup; called AIM (Classic AIM demo video Daniel Rubin AIM related projects).

Structured image annotation will be far more important than structured reporting going forward.

  Now, allow me to finish this extravaganza by putting on my nerdish, science fiction fanatic hat. What could the end game look like for radiologists? "We will control the horizontal. We will control the vertical... For the next hour, sit quietly and we will control all that you see and hear." There will be no reading worklist, no EMR, no reporting tools as we know them. There will be image display software with embedded, speech driven,

[Yes, speech driven, though speech recognition is becoming commodity. (I speculate that Watson, with cash resources nearly as large as compute resources, bought 'eyes' with Merge rather than 'ears' with, for example, Nuance Healthcare since they already have NLP technology)]

 AIM annotation tools, period. Images prioritized (Watson will be an excellent case manager) for human evaluation will be displayed in a pre-determined fashion optimized for the feature detection task at hand. No preferences, no configuration. Your job as a radiologist will be to make image observations and annotate them. Think CAPTCHA: Telling Humans and Computers Apart Automatically on steroids. You will still derive some inferences of value and annotate those as well, but the vast majority of the inferences, conclusions, diagnoses and recommendations will be made by Watson taking into account vast amounts of information of which you could not possibly have knowledge. As the CAD algorithms improve, you will note that certain images (perhaps first, mammograms) no longer flash on to your screen as the algorithms take over. Don't forget, that Watson will not only rely on the image processing results and their accuracy but also everything else known about the patient and their population. Watson will not need perfection in image interpretation to be (statistically) perfect in diagnosis. 

  But wait, Watson, "it dices, it slices and so much more". I believe it was a wise radiologist, Merril Sosman, who is attributed with saying, "You see what you look for; you look for what you know" (in-the-process of being minted, young, whippersnapper radiologists take heed). No one will know better than Watson what Watson knows about a given patient. No one will know what piece of information is the most critical to Watson to improve the power of his calculation than Watson. So I also imagine that you will have an ear piece in place when you are on duty. 200 milliseconds after the image is displayed and you vocalize some annotations, Watson will whisper in your ear, "But did you see 'endosteal scalloping'?"

  Do not mourn, prematurely, the passing of the radiologists. We will still, for now, take responsibility for and manage patient safety, radiation safety, and technologist quality control (garbage in / garbage out still applies). Research in radiology will continue to develop new modalities and techniques to create new image features to be observed but research will decide which are for Watson and which still need to be done by humans. Residents will only be taught in the latter. We have evolved and adapted with technology, perhaps better than any other medical specialty, over the 120 years since X-day. I imagine we will adopt to this change as well without becoming Melkotians. New possibilities will arise (making image observations inside the darkened interior of your autonomous vehicle).
  Every other participant in health care delivery will have to adapt to these changes as well. Just consider, one day Watson will be whispering in to the ear of some internal medicine specialist, "OK, now insert your finger...". "I, for one, welcome our new interpretation overlord."

A great day to be a radiologist

If I remember correctly, it was cool, clear and crisp on that September day in 2012 when I walked into my office. September is my month; I love this weather. My recollection of early morning sunshine coming through the window may now be biased by the events that transpired. It was early, 6:30 or 7, in the morning. I immediately noticed a rather generous basket of individually wrapped Lifesavers candies on my chair. My first thought was that the team had realized my birthday was just a few days away. An envelope was tucked between the candies. This letter was enclosed in the envelope:

It reads,

Dear Dr. Channin, 

 A few months back you read a chest x-ray on a patient named XXX. In the report you recommended that he have a CT scan to determine if something you saw in the area of the right lower lobe was something to be concerned about. We would like to thank you for that recommendation. The recommendation that you made led to the finding of a cancerous mass in its early stages. XXX underwent surgery on XXX to remove the lesion and the lower lobe of his right lung, and the preliminary testing shows no sign of metastasis. As far as we are concerned it was your recommendation that saved his life and made sure that we will have our husband, father and grandfather far into the future. We wanted to send you a thank you and let you know that in our minds you are a life saver.

Sincerely, 

There is nothing that washes away the cares and woes of the day better than a letter like this. I will tell you that you walk a little taller and you whistle a fine tune. For all the talk of radiologists getting out of the reading room to 'meet and greet' the patient, 'make rounds', etc. to make sure of our piece of the pie, there should be an equal amount of talk about hunkering down in the reading room, and doing what we do best for each and every patient. At many institutions, including ours, patients see the radiology reports shortly after the referring providers. We touch every patient, the shadow of whom we see, with the words we put in our reports. Let us not forget this in the day and age of structured reports (RSNA Reporting Initiative) and computer assisted coding and billing. That extra bit of explanation or detail, especially in your recommendations can make all the difference. Reports can be both machine and human readable. Focus on the whistle not the pie.

Day 2: River Road to Rochester

It is cooler today but more importantly less humid. I feel as if a
front has come through but if it stormed last night I made no notice
of it.
We spend the morning in PdC (code for Prairie du Chien; rhymes with
Charlie Sheen). We visited the Fort Crawford museum and what a gem of
a museum it is. Located on the grounds of what was the second Fort
Crawford (then US Sec'y of War), the only remaining building was the
medical building. And what a history it has. For Fort Crawford was
where William Beaumont did much of his work on digestion studying a
french canadien who was shot in the stomach and survived with a skin
flap.
Also of note is that PdC is the birthplace of Walter B Cannon. Those
of a clinical bent attending SiiM by more mundane means will note that
Cannon was the first Gastrointestinal Radiologist having invented the
barium swallow <as a medical student> at Harvard! His likeness adorns
the gold medal given by the SGR to this day, I believe.
The museum though only 3 rooms has a tremendous collection of
medical and military arcana. Very well presented and explained. There
were even early radiographs and a hand held fluoroscope.
Adjacent to this museum is a small museum of the town, also a fun,
quick stop.
We rode north out of PdC along Rt. 35. Here, the Great River Road
lives up to its name. It flows alongside the great river itself. The
river, a deep azure, reaches north and south to both horizons. It is
matched by an endless expanse of clear blue sky. They, together, are
shouldered in an infinite array of greens.
We meander up to La Crosse and Crosse over to Minnesota, there. We
hop on to 90 and zip out to the mecca of medicine. We hope to visit
Mayo tomorrow. Maybe we can pick up Brad with his hog for the end of
the trip. If not, we will at least have a picture of the XRay bike in
front of the clinic!

--
David S. Channin MD
Evanston, IL
David.Channin@gmail.com
(312) 725 - XRAY (9729)
(866) 844 - 6643 (FAX)

5th Annual Ride-2-SiiM is ON: Day 1

Well, another beautiful spring, a hot summer day and another
Ride-2-SiiM. We left Skokie around 2 PM. Atypical, but that, I feel,
will be the key word to this trip. I am accompanied this year, by the
family, in the <sweep vehicle>. Alex, my usual road mate is utterly
occupied with his lovely wife and their beautiful 1 year old. (Astute
readers will remember that she was born just before SiiM 2009!).
We drove westward out of Chicagoland. The heat on the road was
opressive, at least 85. I could feel it beating off the road. High
humidity and an ugly glare only made things worse. The downside to
living in Chicagoland is that you have to ride for an hour and a half
to get anywhere decent.
Eventually, we hit Route 20, the great way west, identified in
Illinois as Grant's highway. Not coincidentally we will follow his way
west to Galena, his home. We have followed this route on many
occasions as Galena is a very nice place to weekend. Lots of outdoor
activities and a lovely downtown strip of fun shops. It is always a
pleasure to wind your way through the rolling farms to get there. Your
wrist tires of waving to all the bikers you pass.
We wend our way north to the Great River Road, paralleling the
mother river north toward her source. Ironically, you cannot see the
river from the Great River Road, at least not the Wisconsin side.
Somehow this fact is missing from the online tour guides. Still we
wind our way through more and more beautiful farmland, the sky pinking
as the sun sets behind imposing yet ultimately impotent high cumulus
clouds. The road winds agreeably through some twisties that challenge
my end of day riding skills but yet invigorate me by reminding why we
ride.
We stop for the night in Prairie du Chien; pronounced not at all the
way my French wife would like. Another great example of small town
mid America.

--
David S. Channin MD
Evanston, IL
David.Channin@gmail.com
(312) 725 - XRAY (9729)
(866) 844 - 6643 (FAX)

Day 3, Mile 1945: Home

<The greatest plans of mice and men oft go astray>. A beautiful morning found us in Robinson, IL, a quick 200 miles from home. A quick refill of the tank and we sped for a mile before my bike quit. Just lost power and slowed as I rolled to a driveway of a cement plant. Starter would not crank, nothing...now they say, all you need is spark, fuel and oxygen to fly down the highway, but the devil is <always> in the details. So, luggage off, seat off, fuel tank up, lots of side covers off...(You have to strip these metric bikes to the bone to service them). Did I mention it is now 90 degrees? I called the guys in service at Riva Motorsports in Pompano Beach, FL (where my Dad shops). Thanks, Carlo. They were great in talking me through a few debug steps but ultimately couldn't help. I found the fuse box and lo and behold the 15 A ignition circuit fuse had blown! Being the saavy traveller I happen to have some spares, two in fact. I replace the fuse and it immediately blows. I try one more and lo, the bike starts. I re-assemble but go nowhere as that last fuse shorts out. Now at this point I should have started a search for the short that is causing the problem...but I opt for the AMA (the other one) Roadside assistance.
Two hours later, we load the bike on a flatbed and head off for Thompson's Motor Sports in Terra Haute, IN. First a shout out to Poor Boy's towing: Thanks Steve and Grayson. Second, let me just say that the reception I got at thompson's was great. The service guys told me they realized I was on a trip and would do their best to get us back on the road. And boy, did they!
We wandered the Honey Creek Mall for two hours. Our return to Thompson's showed Xray ready to roll again. The cause (as explained in great detail by the mechanic): a short just under the fuse box!! I was inches from having been able to fix this myself.
Be that as it may, thanks to the great folk at Thompson's we were back on the road by 4 PM. A four hour jaunt up on the backroads to 94 finally brought us home. A temperature of 57 degrees as night fell added insult to injury caused by the horrible road conditions in Chicago.

An ignomious end, but an end none-the-less. The light was on, the hearth was on and the steaks were ready as we walked in the door. A warm embrace from the wife, the kids and the dog sealed the deal. There is no place like home.

The 4th ride is now in the bag. We'll have to see where the fundraising leads.

Dsc


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Day 3, Mile 1735, Robinson, IL

The home stretch. We are approximately 250 miles out after a lovely evening ride through the heartland of Illinois. We rode up IL 1 along the border of the state. We have avoided most of the heavy weather with the severe thunder storms now below us and moving east.
An easy if not hot and humid ride to the Windy City and back to the real world.

Dsc

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Day 2, Mile 15xx, Take the last to Clarksville

We can be there by 4:30; don't be slow...oh no, no, no...

Well, the rain gear only stayed on for about 15 minutes. Then the heat and humidity were killing us so off they came. The rain was the tail of a front passing north of us so we are in the clear heading north.

Our train will leave Clarksville then head to Evansville, IN. From there, its a straight shot up the IL/IN border home.

Dsc


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Day 2, Mile 1378; the road to Nashville

Bustin' out the rain gear...there's got be a country song there somewhere.

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Day 1, Mile 1316; The nameless road to the secret city

We rode through Gatlinburg which turns into a real tourist town with restaurants, souvenir shops, attractions, etc. It was packed on this hot, gorgeous day. Cars and motorcycles clog the main drag.
We continue on TN 321 but then turn back into the Smokey Mtn National Forest. Rather than continue south down 411 (toward the Dragon), we turn right toward Townsend. What do we find? You guessed YABRR! But this river has a difference: tubers and swimmers! Absolutely enticing. Great pictures.
We continue from Townsend to Maryville and then on US 140 to Oak Ridge, the secret city; home of the Oak Ridge National Laboratory and the Y-12 Security Complex.
Tomorrow, we turn North.


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Day 1, Mile ??, Gatlinburg, TN

We came over 74 West to 26 to Asheville, then picked up 40 over the Smokies. 40 is the park is a great slab; 70 mph through twisting forest.
We then found a small gem, the Foothills Parkway that connects 40 to Maryville, TN. Beautiful. We are continuing 321 S to Maryville re-entering the park.



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Day 1, Mile 1035, Charlotte

The ride home begins. Our first stop is Knoxville, TN. That means, we are <forced> to ride west through the smoky mountains again. Some of the best greenward twisties foisted upon us. It is a dirty job but someone besides Mike Rowe must do it.

Westward, Ho!


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Day 2, Mile 879.5, Brevard NC

A great start to a great day. I decided to head south on 441 to get to 64 E as the latter is marked as a scenic route. THAT is quite an understatement. 64 E is YASRR (yet another spectacular river road). When the road begins with a warning sign, <narrow road and sharp turns next 40 miles; trucks consider alternate> you know life is going to be good. 64 serpentines itself next to the Cullsuja (Tuskagee?) River and then other branches of the savannah river basin. Between the rapids and the waterfalls along the way there is an abondance of spots just beggin' for a visit and a photo (I only gave in half the time). At the end of the first part of 64 just before Highlands is a rest area built into a waterfall. You can even drive dehind the water! Spectacular.
Highlands is a lovely tourist/nature town set as a gateway to wilderness.
From Highlands to Brevard is more of the same; beatuiful twisties, with residential communities springing up left and right. I hope all the folks here are bikers as this is some of the finest bikin' land.
Now on to Charlotte. Gotta meet up with the Old Man.



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Day 2, Mile 810, Dillsboro, NC

What can I say about the Dragon that has not yet been said? It is justifiably the #1 motorcycle road in the US.
US 129 meanders down from Maryville, preparing you gently and progressively for the curves ahead.
The lake formed downstream from the Fontana dam is a saphire gem that extends infinitely in both directions. It concentrates and amplifies the blue of the sky beyond belief.
I enjoyed the Dragon. I would say that it is not so much a question of difficulty as it is a question of concentration. On each curve, you try to remember everything you have learned and then execute. You have to do that 318 times.
I found that a reasonable speed of 35 +/- worked well. I stayed mostly in second, occaisionally third gear. Of course there were a bunch of sport bike riders who zipped by on a number of dangerous occaisions. I can understand why there have been deaths here.
Then you arrive at Deal's Gap: the motorcycle equivalent of the cantina scene from Star Wars. Bikers of every flavor and then some either coming down from the rush or gearing up to go. I get the impression that some of the racers (why would they wear track suits with knee plates if they weren't racers) go back and forth a few times in a day. Yet a lot of casual tourists, yours truly included.
The way out on the NC side takes 28 S through more of the same: twisty passages of green (with a quick stop at the Fontana dam for some grey/brown concrete). Smoky Moutain National Park goes on forever but I finally found a road and more importantly a hotel in the outside world.
All in all a great experience.



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Day 2, Mile 513, Morning from Manchester

Headed out east from Manchester and picked up 66 heading south. 66 is magnificient; a meandering, tunnel through the Daniel Boone National Forest. It was pretty cool as I started out, enough to merit an extra layer. The sun, heading east as I was, was brilliant, reflecting off every drop of dew it could find. At one point I rode through a cloud of fog just in the process of burning off. I caught a photo of a lingering path of said fog peeking out from the treetops where it was caught like cotton on a carpet.
The curves on 66 were just the warmup I would need for the Dragon. In fact, it was a bit reveresed; instead of riding a ridge, I was often carving through (limestone?) canyons.
As a reminder that this is coal country I passed two functioning coal mines as well as a handful of (ungated!) rail crossings.
I stopped for a coffe at a tiny little general store at the edge of the woods. A perfect start to the day.


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Day 2, mile 600, Mid-day

I rolled south from DBoone trying to get back to civilization and Maryville, TN;the mouth of the Dragon.
I noticed that 66 dumped into 25. And 25 leads to the Cumberland Gap! I took a quick (very nice on/off access) detoru into the park. For nothing but to drive up to the outlook point. Lo and behold another baby dragon; a well tended national park rode that switched its way up the Cumberland hills. The view from the outlook is spectacular. You look out on three states; KY, TN and VA.
From there you dip through a tunnel to the other side. And then a quick ride over to Maryville, right?
Easier said then done.
The damn Garmin GPS failed me in my hour of need. It has got some power problems. It doesn't recognize the cradle and doesn't charge from it. I had charged it the night before and was turning it on and off to spare the battery. Unfortunately, now it won't come on. This will be the third time back to Garmin for service! Not recommended!
To top it off, my BB with Google maps had low battery. To its credit, it surviced the day! So I am about 40 miles out from Knoxville trying to figure out how to get to Maryville. Turns out you can't there from here; or just about. There's a lot of construction around Kville, right where I needed to go. So to make a long story short, I spent an hour or so in an involuntary tour of Kville wending a maze of twisty passages trying to get OUT. Did I mention it was 90 degrees! Yikes.

In the end, the brotherhood of the bike came to the rescue. A fellow rider at a gas station pointed me in the right direction to face the Dragon. (He even pointed out the speed trap they set).

Next...the Dragon....


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