TCS Daily

Rebooting Your Doctor

By Glenn Harlan Reynolds - July 12, 2006 12:00 AM

Andy Kessler has worked in Silicon Valley for a long time. He's seen the way that improving technology can lower costs and increase capabilities in all sorts of areas, and now he says that it's time for silicon to do for medicine what it's done for so many other fields.

That's the topic of his new book, The End of Medicine: How Silicon Valley (and Naked Mice) Will Reboot Your Doctor. And he thinks there's plenty of room for improvement. I agree.

Right now, technology isn't doing much. Kessler spent time with a radiologist reading mammograms, and discovered that it's done the same way it was done in the 1950s -- with a light box and a dictation setup. But there's one improvement. Where once two radiologists read each mammogram, now only one does, with the human opinion being compared to that of an expert system. That cuts the manpower needed in half. But it's just the beginning of what Kessler wants to see:

"Doctors hold the expertise. It's imbedded in their brains. ... But in other industries, the expertise is increasingly embedded elsewhere -- in software, in silicon, in routers, in cell phones, in iPods, in Xboxes, in search engines. That's what made Silicon Valley what it is today. You can take intellectual property and embed it on a chip -- to handle telephone calls, move email around, display 3-D graphics for video games and on and on. A dozen guys with no life design the chip and then workerless factories in Taiwan stamp them out by the millions to be shipped in products you and I can buy for under $100. That's scale. ... Yet here is R2. Cancer-identifying expertise is embedded in an algorithm you can buy for $29. Well, you can't buy it. Some weird system of service and reimbursements pays for it. But it's the first crack in the armor."

I hope he's right and that, as he says, "the Geeks are at the gate." Because he's certainly right that medicine up to now hasn't really benefited much from the electronics revolution.

Kessler thinks that things are about to change, and he makes a compelling case, based largely on technology that's already in existence rather than on Kurzweilian extrapolations of technology that ought to be available down the line. He notes that scanners are becoming far more effective, and much cheaper; that DNA-sensing chips are making blood tests for biomarkers indicative of cancer or other diseases much more effective (and cheaper), and that the improvements in these technologies will allow much earlier treatments: Zapping a tumor when it's at the ten-cell stage rather than the million-cell stage, for example.

As I said, Kessler makes a persuasive case, and I certainly hope he's right. (In fact, we interviewed him for a podcast recently, which you can listen to here or in dialup form here and found him pretty persuasive in person, too). But I wonder if the technological progress he describes will occur as rapidly as he thinks, for reasons that are organizational, rather than technical. That "weird system of service and reimbursements" may prove slower to change than other markets.

Kessler's expertise is in Silicon Valley electronics. But those products are usually paid for by consumers. Health care is paid for by intermediaries: government agencies and private insurance companies that are as big, and as bureaucratic, as government agencies. Will they be as swift to adopt improved medical technology as consumers are to pick up the latest Xbox or iPod? I'm not sure. In fact, I almost wonder if health-insurance companies might prefer to avoid diagnosis of tumors at the ten-cell stage, since they might then be on the hook for much more in the way of treatment expense than they would be if they didn't discover the tumor until just before it was fatal...

Kessler recognizes this problem, to a degree -- he jokes that you'd be better off having your health bills picked up by your life-insurance provider, or your death benefits paid by your health-insurance provider, because then their incentives would be aligned with your interests -- and he notes that the tradeoff between treating existing disease slightly more efficiently, and funding research and development that might lead to drastic improvements, is currently balanced pretty strongly in favor of the near term. I think he's right, but I fear he underestimates the difficulty of bringing about the kind of change that would produce really dramatic new capabilities. It's certainly the case that we're a lot more likely to see that sort of thing if health care consumers demand it. Which I guess is a reason to hope that his book sells well, particularly among policymakers and healthcare consumers. Perhaps you should send a copy to your Senator.

Glenn Reynolds is a TCS Daily contributing editor.



Utopian Fantasy
Any reasonable person must concede that healthcare finance is distorted by third party payment mechanisms and the Internal Revenue Code and rapacious attorneys exacting punitive settlements on providers who make life or death decisions without the benefit of 20-20 hindsight. Additionally, one can note that admission to the practice is controlled by medical societies that have erected barriers to entry (such as that supposedly ensure the quality of practice, but seem also to resemble a fraternity hazing).

However, the premise of this book is insane. Mr. Kessler is a quixotic utopian dreamer. Just as Marx intended to be the prophet of working classes (while avoiding the dreary burdens of employment himself), Mr. Kessler, who has no discernable expertise would have us believe that healthcare can be optimized if we just embrace the idea that chips can replace human beings.

While one could easily dismiss these rantings as the simplisticisms of a myopic , an example of the deficiencies inherent in his thesis is in order. The problem is simple. There are many areas of medicine, such as dermatology, that diagnose and treat diseases that have manifestations that can have multiple causes and defy objective assessments. A simple dermatitis can be an allergic reaction, a nutritional deficiency, cancer, an infection, a fungus, or any of a variety of maladies including behavorial or psychological conditions. The same dermatitis might be intractable or readily improved by adding zinc or other nutrients such as Vitamin D or oils to the diet or changing soaps. Other times, steroids or “immunomodulators” might be prescribed. Sometimes more sun exposure helps, sometimes it will exacerbate the problem. Of course, sometimes NOTHING can be done.

Often the most efficient method of diagnosis is trial and error treatment, not only because the condition produces no marker that can be identified more effectively by objective measurements, but because two people can have the exact disease but react differently to the same treatment. Age, sex, health, diet, behavior all need to be considered. The physician needs to be able to employ eyesight, touch and sometimes even smell, to determine the cause, nature and treatment of the problem.

In short, there’s a reason why they refer to the “practice” of medicine and the “medical arts”. Its as much inductive as deductive and defies the type of linear thinking that are so efficiently processed by computers and their algorithmic processes.

Technology is great as an aid to medicine, but it is the servant, not the master.

There's no sense of history
The truth is that doctors have tried technology in the past, gotten burned, and are quite understandably reluctant to get burned again. I'm a network administrator and the husband to a primary care physician. I understand this very well. The real life acceptable failure rates in medicine and mainstream technology are very, very different.

Do you want doctors to adopt technology? It's easy. A new crop come out every year. Make their new offices a technology showcase and make sure that they *work*. In 3 years, the technologists that fitted out Doctor so-and-so are going to be in tremendous demand to refit the entire area's offices in that specialty.

Unfortunately, to get error rates down to the level that are acceptable in medicine, you're not going to have $5 chips flying out of the fabs as components for $100 devices. Our medical malpractice system has assured us of that. Technology has to not only cure the sick, it has to withstand the rage of the families of the dead, some of whom are not rational and take you to court even when there is no error (I speak as a former jury foreman in just such a case).

In short, the problem isn't some inexplicable technology resistence. There are reasons and they are good ones that have to be resolved and most of them have nothing to do with the actual technology.

Adding Value to the Practice of Medicine
"Technology is great as an aid to medicine, but it is the servant, not the master."

I agree in with this statement. However, technology could provide significantly more "aid" than is currently available...some examples:
1) First and moremost, medical histories and test results should be digitized, so that they can easily be shared by patients, doctors, test facilities and hospitals.
2) Doctors could serve many more patients at lower cost with interactive video consultations, as opposed to office visits. If the proper infrastructure existed, most conditions could be intially diagnosed and treated remotely.

"...would have us believe that healthcare can be optimized if we just embrace the idea that chips can replace human beings."

I completely agree that efficiencies from technology will not by themselves optimize medical economics. Optimization will require more competition, less regulation, tort reform and a radical realignment of the role of health insurance.

Both technological innovation and industry reform should be pursued.

Diabetes and the Shuttle Discovery
If you were to engineer a very complex system, like the space shuttle, then you would embed a vast network of sensors to monitor the system in real-time -- the goal being to instantly identify unusual acitivity and to prevent dangers through timely intervention. In the decades ahead, this too will be the approach medicine will adopt. Nano-scale sensors using an array of molecular tags -- embedded in our toilets and sinks, our clothes and shoes, even in our food and drink -- will augment our immune system.

We will store the flood of data on our home computers while commercial applications (think Norton Health Security & Zone Labs Virus Wall) will search for subtle but significant trends, immediately transmitting anomolies and recognizable dangers to our health providers. In turn, doctors will be able to spend more time solving problems and less on diagnosis. And patients will be able to see their doctors when truly needed, and not because of routine scheduling or unfounded fears.

Of course this will take a long time to mature, but the first steps are already underway. Type 1 diabetics are beginning to use technology to properly manage insulin intake.


Insulin pump, glucose system is a significant step towards artificial pancreas technology
Medical Devices & Surgical Technology Week
May 16, 2006

The Juvenile Diabetes Research Foundation (JDRF) said that the federal government's approval of an insulin pump that also PROVIDES REAL-TIME, CONTINUOUS GLUCOSE MOINTORING is a significant step on the path to the development of an artificial pancreas, with the potential to significantly improve diabetes care and lower the risk of complications...

The new device (the MiniMed Paradigm REAL-Time Insulin Pump and Continuous Glucose Monitoring System) was just approved by the Food and Drug Administration. It's the first integrated system for people with diabetes combining an insulin pump with a continuous glucose monitor...

...According to Aaron Kowalski, PhD. (director of Strategic Research Projects at JDRF), research continues to show that current diabetes technology is inadequate. Some studies, he said, have found that even those patients who intensively manage their disease -- measuring their glucose an average of 9 times a day -- SPENT LESS THAN 30% OF THE DAY IN NORMAL GLUCOSE RANGE.

Hi Mr Silicon Valley Dude, I am from the govenrment/law firm/AMA/insurance industry/... and her to h
We define helping you as the following:
1. Creating paperwork.
2. Delaying innovation.
3. Charging enormous insurance rates.
4. Incorporating the efficient legal system at every step of the way.
5. Forcing you to get approval by unknowing third parties aka bureaucrats.
6. Having you submit volumes of invoices and requests for services to other third parties for payment.
7. Forcing you to negotiate rates with people who will not use the products and services nor know how they work or what they are for.

The effect of all this is to grossly increase costs.

And you will fight some paper pusher, government employee or laywer for each and every change you want to make.

Comparing electronics to health care we get:
1. 50% of health care is paid by various levels of government. 80% by third parties. How many third parties pay for those ipods. What percentage of big screen televisions are brought on government contract?
2. There are gigantic awards for malpractice lawsuits that have insurance companies cringing? Are they any for Ipods, DVD players, personal computers?
3. Suppliers to the health care industry must submit everything to god, aka FDA who can approve or dissaprove anything at will. Is there a EAA, Electronics Approval Administration approving EVERY single part of the electronics business from development through manufacturing to wording on the marketing materials.

I don't think so. In fact I think all this foolishness in the Health Care industry is just that. But I am only one person and their side has millions of people who are vested in keeping theses processes running just as they are.

But good luck....

Do you agree?
Should their be a minimum legal requirement of professional competence for doctors, nurses, etc.? Yes.

Should their be a consistent, public definition of what constitutes professional competence? Yes.

Should the public have the ability to seek redress when injured by unprofessional conduct or insufficient knowledge? Yes.

I suspect thay you will agree with all three statements. Furthermore, I suspect that your issue is not with the licensing of medicine or lawsuits, but the abuse thereof.

Ahhh, No, No, and No but.....
Private organizations could easily define what their competence levels and how doctors match them. The AMA, College of Pediatrics, etc are more than able to handle the job.

No, the public does not exist. Professional competence is a subjective evaluation that need be made ONLY by the patient and or patient's representative based on lots of criteria.

No, the public does not exist. Individuals do. Individuals should be able to see civil redress, but only when the redress is rational. A wrongful death punative damage of 250 million for say Vioxx is not exactly rational. The solution here is to have the patient or patients representative meet prior to the procedure and agree on compensation for these kinds of things.

Public Rights
Both the Public and the Individual were both recognized by our founding fathers when they created the Constitution. For example:

The Federalist No. 51
The Structure of the Government Must Furnish the Proper Checks and Balances Between the Different Departments
Independent Journal, February 6, 1788

...If men were angels, no government would be necessary. If angels were to govern men, neither external nor internal controls on government would be necessary. In framing a government which is to be administered by men over men, the great difficulty lies in this: you must first enable the government to control the governed; and in the next place oblige it to control itself. A dependence on the people is, no doubt, the primary control on the government; but experience has taught mankind the necessity of auxiliary precautions.

This policy of supplying, by opposite and rival interests, the defect of better motives, might be traced through the whole system of human affairs, private as well as public. We see it particularly displayed in all the subordinate distributions of power, where the constant aim is to divide and arrange the several offices in such a manner as that each may be a check on the other -- THAT THE PRIVATE INTEREST OF EVERY INDIVIDUAL MAY BE A SENTINEL OVER THE PUBLIC RIGHTS. These inventions of prudence cannot be less requisite in the distribution of the supreme powers of the State.

- James Madison

More by Madison
Letters of Helvidius, nos. 1--4
24 Aug. -- 14 Sept. 1793
Writings 6:138--77

Public rights are of two sorts: those which require the agency of government; those which may be carried into effect without that agency.

As PUBLIC RIGHTS ARE THE RIGHTS OF THE NATION, NOT OF THE GOVERNMENT, it is clear, that wherever they can be made good to the nation, without the office of government, they are not suspended by the want of an acknowledged government, or even by the want of an existing government; and that there are important rights of this description, will be illustrated by the following case.

Suppose, that after the conclusion of the treaty of alliance between the United States and France, a party of the enemy had surprised and put to death every member of congress; that the occasion had been used by the people of America for changing the old [pre-Constitution] confederacy into such a government as now exists, and that in the progress of this revolution, an interregnum had happened: suppose further, that during this interval, the states of South Carolina and Georgia, or any other parts of the United States, had been attacked, and been put into evident and imminent danger of being irrecoverably lost, without the interposition of the French arms; is it not manifest, that as the treaty is the treaty of the United States, not of their government, THE PEOPLE OF THE UNITED STATES COULD NOT FORFEIT THEIR RIGHT to the guaranty of their territory by the accidental suspension of their government; and that any attempt, on the part of France, to evade the obligations of the treaty, by pleading the suspension of government, or by refusing to acknowledge it, would justly have been received with universal indignation, as an ignominious perfidy?

- James Madison

Ott The Mathematician?
Just curious -- are you the William Ott that co-authored "Prevalance" with James A. Yorke in the AMS Bulletin (March 2005)?

I certainly hope something happens, but wish to suggest another area that needs help even more than medicine, that is education. WE must somehow change the way education is done, which for the mst part is badly. Some handheld devices are required!!

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