Excerpt from Kessler's 'The End of Medicine'

The same technology and silicon and 3D algorithms we play around with every day are about to invade medicine. The following is an excerpt from Andy Kessler's new book, The End of Medicine: How Silicon Valley (and Naked Mice) Will Reboot Your Doctor.

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 7^th 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 3^rd 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.

Too many investigations = too many false positives

[neoshmengi]

You get to a point with investigations where more isn't necessarily better. There is always a chance that a scan will show a false positive. You see what looks like a suspicious nodule in an asymptomatic patient. Now you have to do more investigations, and some investigations carry a risk. Finally they decide to biopsy the nodule to see what it is and it turns out to be benign. The end result can be a patient exposed to unnecessary radiation, surgeries and/or worries. That's why it's nice to have doctors who decide who and when to scan. 'Magic Scans' aren't the panacea they are cracked up to be.

That being said, it is incredible what technologies are doing for medicine. Some of the stuff in medical textbooks is obsolete, particularly clinical findings, because you almost never see that disease advanced to the degree that the book describes as we get better and better at finding things early.

So like the other poster said, sign up to get your screening colonoscopy today! (provided that your 50)

Re:If high-tech medicine is so valuable...

[geohump]

Simple, For the first one, The people who need the most help with chidbirthing and pre-natal can't get it. They don't have health insurance or money. In the US that sentences you to almost no health care, except emergency room visits.

For the second one "HFCS" (High Fructose Corn Syrup) and Portion sizes

The use of HFCS in American foods have gone up by several hundered percent over the last 30 years and portion sizes in most restaurants have also gone up, largely due to the influence of the Super sized portions being marketed by the fats food chains. (and no "fats" wasn't a typo there. :)

Get the book "fat land " by Greg Critser from your library, small book, quick easy read, explains what happened economically and calorically to America since Earl Butz "saved the American dinner budget". Also goes into what HFCS is doing to kids in terms of causing early onset of Type II (adult) diabetes.

For the third one (mumps), many people no longer believe that vaccinations are needed. "we got rid ofthat disease didn't we?" They will change their mind after someone in their family gets crippled or killed by one of the dieases we "got rid of".

algorithms are rarely new

[peter303]

In my experience algorithms are rarely monopolized by any single field very long and fairly quickly find themselves distributed across all sciences and engineering. For example the algorithm of tomographic inversion was picked up by seismologists, astrophysicists, meteorologists, material scientists, etc. for similar situtations in their fields. Likewise radiology engineers monitor devlopments in image processing and 3D graphics to construct even move vivid and useful body images.

Re:Computer technology will help not eliminate MDs

[Ced_Ex]

Well... at some point the computer should be able to handle most situations where we can say with near 100% certainty that if x happens, we apply y. Example: Broken femur happens, we apply splint/cast, and so on.

We will however, will still need doctors for times when the patient has multiple symptoms that point to n number of problems and solutions, but the real problem needs to be flushed out before anything can be done.

Doctors will never be eliminated.

Larry Weed, medical visionary

[harmlessdrudge]

One of the most interesting lectures I attended as a graduate student (at Ohio U.) was by a visiting MD from Harvard. Larry Weed was his name. His basic thesis was that the medical profession couldn't keep adding new "ologies" (immunology, embryology, etc.) to the curriculum indefinitely and that at some point it would be necessary to a) teach people how manage information better and b) provide them with computer based tools which could allow them to work with probabilities and the underlying literature. For example, if abc then the odds are 85% and here's why (links to primary literature). Weed developed the idea of the "problem oriented medical record," spoke about online access to epidemiological data that would allow more rapid detection of drug interactions and the like. What was most interesting was the reaction of the audience: deeply skeptical. At one point Weed reeled off a some symptoms of a sick child and challenged the audience to reason what was wrong. The very cocksure medical students needed reminding at one point "this is not a multiple choice quiz, a child's life is at stake." Weed made his points well. Even then (mid 80s), long before Google, one could hardly doubt that he was onto something.

However, I googled him recently out of curiosity to see what had happened to him and his ideas, 20+ years on. I have to say that the results were remarkably disappointing. It seems that Larry Weed was too far ahead of his time and may still be. Check out his company at http://www.pkc.com./ [www.pkc.com] One rather dramatic quote of his: if physicians ran airports they wouldn't have radar, just lots of intensive care units around the periphery.