"The End of Medicine: How Silicon Valley (and Naked Mice) Will Reboot Your Doctor" by Andy Kessler, Collins, 354 pages, $17
Anxiety hit Andy Kessler after his good friend Brad Miller suffered a strong blow to his head while skiing in Sun Valley, Idaho. When doctors suspected a broken vertebra, X-rays were ordered, followed by CAT scans and an MRI, which showed that Brad had a tumor at the base of his skull. He began chemotherapy and radiation treatments. As if that were not enough, a week later Kessler's brother-in-law suddenly had a heart attack in the middle of the night. Kessler, 47, panicked, and went to his family doctor for a physical.
The doctor checked Kessler's blood pressure and cholesterol; then he pulled out a rubber hammer and tapped his knee. At that moment, Kessler - an engineer who spent many years working in California's Silicon Valley and was later an analyst on Wall Street - understood that medicine was very sick. Can a rubber hammer diagnose a hidden tumor? Can doing blood tests and checking cholesterol levels predict tomorrow night's heart attack? Unlike Silicon Valley, which undergoes a technological renewal every 18 months, medicine has not changed much over the last decades. This insight led Kessler to a long journey aimed at exploring the various maladies of medicine and of the health-care system.
A diagnosis of heart disease is based today on blood pressure and cholesterol tests, although the level of cholesterol in itself cannot effectively point to the existence of an atheromatous disease in the cardiac arteries and is more or less a rough guess. The only reliable test is coronary catheterization, but it, too, is limited: It is an imaging technique providing two-dimensional information; it is costly ($5,300 for a diagnostic procedure, $14,784 for a therapeutic one); and, above all, it is invasive and dangerous, and carries a risk of complications (bleeding) and even of death (two fatalities for every 1,000 procedures).
The advanced technological substitute - a virtual catheterization using a CAT-scan machine - provides three-dimensional imaging of the arteries during a quick, noninvasive scan (it lasts only a few seconds). The new scanners provide 64 slices of an organ in less than a second. Future scanners will provide 256 and even 1,024 slices with every rotation of the tube. The problem is the price: Only when the cost of the procedure (which now stands at $2,000) drops, will mass screenings will be available as a tool for the early diagnosis of obstructions in the cardiac coronary arteries, so that heart attacks and sudden death will become a thing of the past.
Old and new
As part of his journey, Kessler visited a facility where a 70-year-old radiologist read mammograms by holding a magnifying glass over the films for hours. To the author's surprise, the doctor checked his diagnoses against an R2 computerized workstation. The computer compared the films to a database containing tens of thousands of mammograms with pathological findings. When an image turned up something suspicious, the computer sounded the alert and flagged it in bright red on the screen - all within 30 seconds.
Since the law requires that each mammogram be read by two expert radiologists, the U.S. Food and Drug Administration (FDA) has allowed computerized diagnostic stations to replace one human radiologist. It has been proved that ever since they were introduced in 2000, the stations have raised the accuracy of breast-cancer diagnosis by 19 percent. The cost of a computerized mammogram reading is $29, while having the films read by a radiologist costs $110. The expenditure saved is enormous, if we consider that some 40 million mammograms are performed each year in the U.S.
These examples and others led Kessler to propose a new paradigm: The world of technology is coming faster than expected to medicine, which is now conducted in an anachronistically conservative way. Diseases will be diagnosed before they erupt, treatment costs will drop radically, and all this will go hand in hand with improvements in the expectancy and quality of life. To my colleagues, the doctors, Kessler bears a grim message: Your time is up; your profession, in its current form, is obsolete. Technology will take over, and you will lose your jobs. Look for a new profession right now - or else upgrade your practice of medicine. Otherwise, you will be lining up at the unemployment office before the month is over.
The technological revolution has already changed many areas of our lives, and Kessler provides plenty of examples. Internet tourism sites provide varied information with a few clicks of the mouse, an efficient substitute for the travel agent; a tiny electronic chip in our car diagnoses malfunctions much more quickly and effectively than any skilled mechanic; and practically all the knowledge and banking services once provided by tellers can be found in the advanced software operating 24/7 at automated teller machines.
Medicine, Kessler claims, will not escape the same fate that Microsoft and Intel have imposed on most aspects of our lives. In the health-care system of the future, clients will traverse a digital route during which their insides will be scanned; the results will be instantly compared with a computerized database (containing endless terabytes of information), producing a diagnostic output as well as an up-to-date therapeutic plan. The process is clear, one- directional and cruel. Technology derives knowledge from human beings and, after following its convoluted path of evolution, finally makes them unnecessary.
Medicine as we know it is based on HMOs and clinics, but in its essence the profession relies on the knowledge of learned people (we, the doctors) who have memorized endless facts, data and numbers, and who try to implement this knowledge in caring for their patients. But the doctor is too costly a resource for health-care systems. The lines of people waiting for the family physician or specialist are getting longer, while the actual encounter with the doctor is getting shorter: five or 10 precious minutes for each patient, during which the doctor must take a medical history, listen (!?!) to the complaint, mutter a few words, do a brief physical exam (if at all), recommend treatment, give detailed instructions, write the prescription, update the patient's medical record ...
Technology today already offers an alternate route promising a higher quality of diagnosis and care and, above all, much lower costs: Sending the ECG of a person complaining of chest pains to a computerized diagnosis center reduces by some 85 percent the number of cases which end up in the emergency room; X-rays, CAT scans and MRI results from New York and Philadelphia are sent to Delhi, Bangalore or Beit Shemesh, and deciphered there with the help of digital software. These algorithms have already replaced radiologists in diagnosing breast tumors, finding pulmonary nodules or locating colonic polyps. In the future, they will enable emergency room diagnosis of atherosclerosis in the coronary arteries (a worthy substitute for today's primitive ECGs). Minimally invasive laparoscopic procedures have in the last decade come to replace large, complex operations involving the surgical opening of the abdomen.
The future lies in the hands of computerized robots performing surgeries and procedures by remote control. Without noticing it, we have already entered the world of digital and virtual medicine, and this is only the beginning of the revolution.
The medicine of the future will be preventive in nature. Farewell, therapeutic care. Instead of investing enormous budgets in treating chronic diseases, a routine scan of healthy people will identify the potential for the disease even before it develops. Nanotechnology, molecular imaging and microscopic silicon chips will be the magic wand that eliminates from our lives the three main killers: cancer, heart disease and strokes. Health-care costs will drop dramatically when diseases are eradicated before they appear, and this process will allow funds to be channeled into other areas, leading to economic growth.
Kessler looks at medicine through the eyes of an economist; as a former analyst for Morgan Stanley, he relies on his own expertise in venture capital and hedge funds, and predicts the next silicon revolution - in medicine this time. If his predictions prove true, the big bucks will flow into medicine, where the next big economic boom will take place. Life insurance companies will be the first to require that every client undergo arterial scans, protein and DNA tests, and molecular imaging to identify potential diseases as a precondition for insurance. This will lead to the establishment of many innovative new biotechnological start-up companies; funds from Wall Street and Frankfurt will invest in them; and so the biotechnological boom will come into being.
In his previous books, "Wall Street Meat" and "Running Money," Kessler offered a razor-sharp analysis of high-tech firms in the merry days of the bubble; he predicted that the bubble would burst and later also foresaw that technology companies would rebound. He peppers his analyses with stories and amusing anecdotes that make reading a lightweight, delightful journey. At the same time, his ideas are original, profound and certainly thought-provoking. In his latest book he predicts not the end of medicine, but rather the dawn of a new, promising and fascinating medical age.
Dr. Elisha Bar-Meir is head of the Radiology Department at the Bnei Zion Medical Center in Haifa.