Excerpt from Kessler's 'The End of Medicine' 116
CT Anxiety
I always feel a certain anxiety when I walk into the Hyatt Regency at the bottom of California Avenue in San Francisco. The cutsie Trolley car outside, the Embarcadero tile pattern on the sidewalk — they are all part of the package. But as I've done every time I've been there, I head straight into the lobby, tilt my head back and scan the Escher-like floors, starting at the top and then down and outwards to the bottom until I start feeling dizzy. I thank Mel Brooks for this.With my head spinning from this "High Anxiety" flashback, I stroll into the conference, half expecting to be given a barium enema by a cross between Nurse Diesel from Mel Brooks' flick and Nurse Ratched from One Flew Over The Cuckoo's Nest. I really gotta switch to decaf on days like this.
The 7th International Multi-Detector Row Computed Tomography Symposium sounded innocuous enough. I assumed it would be a bunch of technical papers on the future of scanning, where I would read the paper in the darkened hall until lunchtime and then head off for some hot Hunan and home.
Instead, the place was like a carnival for cardiologists. Talk about feeling like a fish out of water. Outside the hall was an expo of sorts, with big signs flashing Toshiba and Philips. Instead of TVs or microwave ovens, there were PCs with 3D models of some poor schmuck's diseased coronary arteries being folded, stapled and rotated.
The back wall of Toshiba's booth caught my eye and I just stared at it. Rule number one at any tradeshow booth is never look interested or you are doomed to a rapid-fire ten-minute lecture on the ins and outs of the product and forced to give up your card as a qualified lead, to be hounded by phone, fax, email and snail mail for the next year.
"Those are our detectors." Damn, I was snagged.
"They look like the display on my laptop," I noted.
"Well sure, they are not that much different from a flat-panel display."
"Same economics making them?" I asked. Flat panels are notoriously expensive to manufacture, because of their size, unlike chips, where hundreds can fit on an eight-inch diameter wafer.
"Oh no, as we go from 4- to 16- to 64-slice, the detectors can be manufactured discreetly and butted up against each other. We don't have yield issues."
"How much is one of these 64-slice scanners?" I asked.
"Are you ready to buy one today, or this month?" booth-guy asked me.
"No, no, although I wouldn't mind one in my garage. I'm a tech guy."
"Oh, OK. Well, these are basically one- or two-million dollar machines."
"Wow." I wasn't sure if that is a lot or a little, but often a well-placed 'wow' gets you all sorts of inside scoop.
"I know, pretty cheap. We think we have a variety of advantages over the competition and you will see in the face-off that ..."
"Why so much? I've been in enough factories, and those flat panels are a couple of hundred bucks each and the motor to rotate can't be more than ..."
"Well, the X-Ray source is not inexpensive."
"What? Hundreds of thousands of dollars?" I trolled.
"Probably not. We do have high selling expenses. When you only sell a hundred of anything, there is lead generation and a sales pipeline and funnel."
He started whispering. "They could be a lot cheaper." He must be having a tough month.
"Don't let me stop you, by the way," I said, looking around, trying to imply he should hard sell some of these cardiologists and radiologists who were buzzing around the display.
"Doctors aren't buyers, not for these machines. We sell to a few clinics. The rest is into hospitals - they are the only ones that can afford them for now."
"But you said cheaper — I mean, these can be in the hundreds of thousands of dollars instead of millions." It was a statement dressed up as a question.
"Someday," he whispered, again.
That's all I needed to know.
Several times, I heard references to the big face-off that afternoon, like it was the reason everyone was there. "Don't miss the face-off," "This ought to show well at the face-off," "This year is going to be so much better than last year's face-off." OK, I get it.
I sat down in the auditorium and the talks and dim lights put me right to sleep.
The head whips woke me up, as my neck turned into Jello and my chin dug into my chest. I wasn't sure if I was awake, my heart was beating fast - I was on the top floor looking over the rail next to Mel Brooks ... Nope, I'm OK, I'm awake, although embarrassed as quite a few radiologists turn to see what the commotion was in my seat.
"Ladies and gentlemen, welcome back, take your seats, fasten your seatbelts, this is going to be exciting. I am pleased to announce that for our 3rd Annual Workstation Face-off, we have five different vendor groups competing — well, facing off. We have five different data sets: brain, runoff, lung, colon and heart."
The room exploded in applause, like this was some sort of important revelation.
"On the stage, we have workstations from GE Healthcare. Dr. Gruden, please take a bow. Also Vital Images, Philips Medical Systems, Siemens Medical Solutions and TeraRecon. May the best workstation win. Let's get started."
The room was buzzing. On stage were two giant screens. On the left was a view from the monitor of the workstation and on the right was a live feed from the operator's keyboard and mouse so the audience could see how many clicks and keystrokes and other contortions are needed to get through the data set.
"OK, let's start with the brain. GE, you have six minutes for both the Angiogram and the Perfusion. Go."
A giant clock on stage started counting down from 6 minutes. The doctor operating the GE workstation was furiously clicking and slapping his mouse around and on screen; we all could share his view zooming through someone's brain.
"OK, we can see the internal carotid artery on the right-hand side, so now let's quickly move over to this area on the left, ah, not hard to find, there it is, we see the ICA stenosis, let's measure it, 63% blockage." A smattering of applause. "We can zoom in and clearly delineate the calcified vs. the soft plaque." More applause.
"OK, let's quantify the infarct core ..."
I was transfixed. This guy was zooming through someone's brain like it was a Sunday drive. More like a Sunday afternoon video game. I kept looking for a brain in a jar of formaldehyde labeled "Dysfunctio Cerebri — Abnormal Brain" and Dr. Frankenstein's assistant Fritz limping back to the laboratory.
"Let's mark this tissue at risk for infarction and measure some things while we are over in the left cerebral - OK - MTT is 86.7, TTP let's call it 52.5 ..."
He zoomed around the brain like it was just a bunch of bits on the screen, which of course it was. Duh.
"OK. Time. 5 minutes 32 seconds. Very nice. Thank you," the moderator said. The place went crazy. This was repeated on each of the workstations by different doctors to often-thunderous applause. I had a mild headache from all the excitement.
I watched these workstations find aneurysms in the arteries from the waist down, the run off. The trick is to remove the bones from the view and be left with just the arteries. Jeez, everyone knows that. Even I could find the mild aneurismal dilation of right renal arterial trifurcation! But my feet started to hurt and I looked around and lots of folks were rubbing their calves.
In the lung, the fly-throughs were looking for lobe nodules, which weren't so obvious. It was a maze of tubes in there — who can even find their way, let alone in under 4 minutes? But sure enough, there was the posterior and the one adjacent to the heart. Each of the five operators then went back and compared them to a study from three years earlier, after finding them in the previous study, of course. Pretty cool. Does my doctor have this? I coughed, more of an unconscious reflex than anything else.
"OK, a perennial favorite, let's move on to the bowels. This year's virtual colonoscopy will require identifying and measuring five different polyps as well as comparing supine and prone data sets to differentiate stool from polyps."
There was a gasp from the crowd, probably from all the men over 50 who have not-so-fond memories of their real colonoscopies.
"The folks from TeraRecon will go first." "Thank you. For this data set, we have decided to show off our handheld interface device. It is a two-handed device, requiring minimal keyboard usage."
On the right-hand screen, the view zoomed into the doctor's hands wrapped around what looked like a Nintendo or Sony Playstation controller. He was banging it and twisting it around, not much different than my kids playing Halo 2. Except that on the left-hand screen, instead of you as Master Chief blowing away the Covenant to stop them from destroying Earth, you are Master Doctor searching for cancerous polyps extracting revenge and trying to destroy your patient. Or something like that. And you only have six minutes and a crowd of a thousand to cheer you one.
"OK," the doctor running the TeraRecon station said, "let's go into C.A.D. mode to navigate through the colon."
On screen, the screen started flying through the wrinkled walls of the colon, twisting and turning, to the left, sliding over, turning up, then right, around a corner, then down again until it saw something abnormal and stopped in front of a hanging polyp. Ah, that's what Steve Sandy was telling me about.
Massive applause.
TeraRecon found all the polyps and so did everyone else. It wasn't hard, those polyps hung like fruits from a tree, pretty obvious against the background of the empty colon. Each of the operators had to go to the alternate data set to show that a few potential polyp looking globes were nothing more than a pile of, well, stool.
My cough had mysteriously turned into a pain in my lower gut.
"Now, what you have all been waiting for, the grand finale, someone left their heart in San Francisco."
On screen was a giant rendering of a heart and most of the coronary arteries. It might as well have been pumping and spraying blood all over the audience like the movie Carrie, there was such a frenzy.
Each of the workstations zoomed in, probed for diameters of sinotubular junctions and aneurismal sinuses. Ho hum. But in no time, each found blockages, stenosis that either had already caused a heart attack or was about to any day.
I just stared at the screen. My eyes were wider than Marty Feldman as Igor in Young Frankenstein. It's not some dream of the future, there it is in front of my face. I felt some pains on the left side of my chest, but my stomach ache went away.
This is it. The resolution was high enough, and there was plenty of speed to zoom around and find all the gunk in less than five minutes. These guys could peak inside and tell me if I was going to have a heart attack, before I do, before I drop on the floor grabbing my chest and my wife screams to the 911 operator to get someone there as fast as they can, before all my relatives get the call saying Andy has had a heart attack, before I get overloaded with blood thinners and can't remember what day it is.
This changes everything. Blood pressure readings, cholesterol checks for low-density lipoproteins, echocardiograms, all that stuff is primitive stuff, like silent movies — OK, another Mel Brooks reference. It just has to be cheap enough and it will be as routine as the doctor banging your knee or squeezing the crowned jewels.
Let's see: $2 million machine, 5 minutes per patient, of course, that means
144 a day, 720 per week, 36,000 per year, hmmm, that's $55 per scan.
Add a little for the attendees and five minutes of the radiologists
time and voila, maybe this is a mass market thing after all.
Andy Kessler is a former Bell Labs chip designer, turned Wall Street analyst and hedge fund manager turned author. Sounds like he can't keep a job. See this book's page at Amazon.
Virtual vs Actual colonoscope (Score:5, Informative)
So what to do if you find a polyp? - get an actual colonoscopy of course, so that they can snip it off.
While most people don't look foward to having this done, it's still probably the best way to have your colon checked out. Everyone over 50 NEEDS to have this done. Missed colon cancer can lead to a colostomy - yeeecch! - or worse. So put up with the distastefulness of it and get it done, or convince your parents to get theirs.
nothing new here (Score:4, Informative)
As an undergrad in the 80s, I worked with some computers in a university chemistry lab. In this lab, one of the research professors was developing "shape fitting" methods to design drug molecules. Need to attack a certain receptor? Design a drug that fits. Need to protect a certain receptor? Design a drug that plugs the hole until the intended natural molecule is present. It was all very next-century super-futuristic stuff.
Now that computers should be able to handle that task easily, I rarely hear anything about it anymore. And honestly, there's a lot more than geometry and a few chemical bonds that need to be better understood. We all thought buckyballs would be completely inert and pass through the system... until we actually found that living bodies can get choked up with them. It's like explaining how bees fly-- there's a lot to the science which is still just guesswork and lab experiments.
Lastly, it may be great if a new treatment helps 94% of patients... unless you fall in the 6% it doesn't help. Everything is statistical until it's personal. There are a lot of areas of the response tree which are not known, or even if a certain branch of pathy is known, there are risks in all modes of treatment.
Somehow, I don't think human fuzzy-thinking seat-of-the-pants gut-instinct doctors will be replaced with deterministic analytical machinery anytime soon.
Radiology (Score:3, Informative)
I have been running a radiology IT company for the last 4 years and have been involved with radiology in one way or another half my life (all of my life if you count my father as being a radiologist). I frequent medical technology trade shows and have seen quite a bit of this 3D post processing.. Very intriguing stuff and the resolution on these machines is very beautiful, I often wish my home PC could render the same resolution as these machines. Doom 6 would be the next best thing to sex..
However, I don't think any machine will be capable of replacing a medical professional in the next 20 years and I really feel there is only one major reason holding vendors back: liability. The human body is simply too complex for a computer to check for issues, understand complications, diagnose and recommend further action.
Currently the systems can highlight and pinpoint potential problem areas, but these systems still rely on a medical professional to review and approve the findings. From what I here the systems are pretty good at finding "problem" areas but offer a lot of false-positives that the doctor has to check out.. thus negating any upper hand advantage they gave in work flow optimization.
Re:PLEASE FRIGGIN' DO! (Score:4, Informative)
Designing drugs (Score:3, Informative)
Now that computers should be able to handle that task easily, I rarely hear anything about it anymore...
You have to find the receptor. You have to design a drug to fit in the receptor. You have to figure out (mostly guess) whether or not the drug will actually bind at the receptor. You have to figure out (at least guess) as to whether or not the drug will kill people in addition to stopping acne. You have to figure out how to make the drug. Then you have to actually go through all the trials.
If you mass test random potential compounds against random proteins, you get to cut out some of those steps.
There are companies that do the designer route, but it seems like most go for the shotgun "spray a bunch of compounds at a bunch of proteins and see what sticks".
Really, we don't even know how these proteins are gonna fold, so we're a ways away from automating designer drugs.
*I am not a biologist, chemist, physicist, etc. I'm a programmer.*
Re:Star Trek predicts the future again. (Score:3, Informative)
I was talking about the communicators in The Original Series, not from The Next Generation. They looked very much like today's flip phones.
Nor was I talking about stun guns. We do have honest to goodness laser weapons now, which at this point only cause blindness, but there are also weapons under development that will do further damage.
http://en.wikipedia.org/wiki/Personnel_Halting_an
There is also a laser-equipped 747 that can shoot high-powered beams at a given target.
http://www.defensetech.org/archives/000551.html [defensetech.org]
The tricorder is also a real device, although the technology still has a long way to go.
http://www.stim.com/Stim-x/0996September/Sparky/t
Transparent Aluminum, first introduced with ST4:The Voyage Home as the superstrong "metal glass" used to haul two humpback whales back to the 23rd century, is also the real thing.
http://en.wikipedia.org/wiki/Transparent_aluminum [wikipedia.org]
I don't smoke anything, not even tobacco.
Re:If high-tech medicine is so valuable... (Score:4, Informative)
Life expectancy I have no easy answer for, although our diet has some serious problems, and I believe our "scientific" nutritionists have gotten stuck on some bad memes and no science, and have merely made the problem worse.
And as for dying of the mumps, there are several old diseases that are making a comeback. Some jackass started spreading the unsubstantiated rumor that vaccines cause autism (even if they did, the effect would have to be undetectable if it went unnoticed this long and lots of things have little undetectable effects), and as a result a large number of people have been "saving" their children from vaccination. As this passes a critical percentage, the disease begins to resurge. Measles are also doing this, from what I understand. Unfortunately, correcting this problem is quite difficult as it plays into the paranoia meme; anybody with the authority to tell people this isn't true are themselves part of the conspiracy. But it has more to do with freedom to not vaccinate than the health system per se. (A freedom that may well be taken away at some point if the diseases continue; public health tends to override a lot of other rights.)
The US does have an obesity problem which I believe is caused more by diet and the lack of true science than anything else, and that hurts some of the statistics. Other than that, if you want the best treatment, you by-and-large come to the US. (There are some exceptions, mostly in treatments that have not passed FDA approval. One can argue about the FDA's thresholds, but it's hard to find an objective standard there.)
It's fashionable to bash the US, and fashionable to bash "Western Medicine", and bashing US Medicine gets you two for the price of one. But that's all it is: fashionable, built on anecdotes. Not terribly well grounded in data.
Re:Diagnostic toys NOT a substitute for good docto (Score:1, Informative)
Re:Diagnostic toys NOT a substitute for good docto (Score:5, Informative)
(a) antibiotics don't treat Lyme immediately. It can take weeks to months to completely remove the bacteria from your body. Thus, the usual course of 10-days of antibiotics at a normal dosage would have done little or nothing (also, when you start antibiotics, Lyme often gets worse, not better).
(b) the Lyme symptoms are close to many autoimmune disorders, and thus can be mistaken for such. Thus, some doctors have prescribed steroids - corticosteroids lower immune responce, which is the exact opposite effect than the one desired.
-b.
the future is arriving more slowly than you think (Score:3, Informative)
Nooo, I'd say you don't hear so much about it anymore because (1) the idea is no longer new, and (2) it isn't working out as well as we'd first hoped, and perhaps (3) you're not in the field. We've a loooong way to go before rational drug design in silico becomes truly routine. At the moment it's a big help to the trained chemist, but that's it.
A couple of problems remain:
(1) Often enough, the molecular structure of drug targets are a mystery. Most often, it's a mystery clinically, in the sense that no one knows the target molecule or even the target biochemical pathway. How do you fight the development of atherosclerotic plaques in the coronary arteries? Given that we have incomplete knowledge of how it happens, it's very hard to identify a target for drug therapy. Here genomics and proteomics, e.g. the correlation of the expression of certain proteins with certain clinical conditions will undoubtably help.
Even in cases where a target is known, it may well be a mystery physically. It's very difficult to crystallize proteins to determine their 3D structure. I think good labs can do maybe 3 or 4 a year. More vexing is the fact that probably a lot of useful targets are on cell membranes, and membrane-bound proteins are usually impossible to crystallize at all.
(2) The solvent has a profound influence on the interaction between macromolecules and possible ligands, so computer simulation of these systems has to take good account of the solvent. But the solvent (water) is small and moves on a femtosecond time-scale, while the interactions of interest are maybe 5 to 10 orders of magnitude slower. That means your computer spends essentially all of its time simulating (useless) solvent behaviour, and very little simulating interesting protein/ligand behaviour. The problem grows exponentially with the size of the system of interest, so it can't be solved even by Moore's Law. Better theoretical models of solvent are needed.
(3) The interactions that govern the dynamics of these systems are strongly many-body, but the calculation of true many-body dynamics is prohibitively expensive. Inevitably simplifying approximations are made, but that tends to reduce the utility of the methods, because the approximations must be validated in a system not too dissimilar from your target system. That means you have to have some independent means of knowing the behaviour of a system not too far from your target system to validate your computer model. That makes them less generalizable and useful than one would hope.
That said, it's an area of vigorous research and much progress. There have been some noteable successes. But the idea in the 80s that by now we'd be routinely designing drugs by computer simulation is sort of like the idea in the 60s that by 2000 we'd have moon colonies and be routinely sending manned spacecraft to Mars. The future is arriving more slowly than we'd hoped. As it always does, except maybe around April 15.