Do we need Doctors or Algorithms?

This fascinatingly detailed TechCrunch article by Vinod Khosla, the billionaire founder of Sun Microsystems and Khosla Ventures, makes nearly every mistake that I notice technologists making when they try to suggest how technology should change the way Healthcare works. As such I think it makes for an interesting dissection:

I was asked about a year ago at a talk about energy what I was doing about the other large social problems, namely health care and education. Surprised, I flippantly responded that the best solution was to get rid of doctors and teachers and let your computers do the work, 24/7 and with consistent quality

Great idea. I wonder how this is going to work?

‘Doctor Algorithm’ or Dr. A for short… …will get better and better and will go from providing “bionic assistance” to second opinions to assisting doctors to providing first opinions and as referral computers (with complete and accurate synopses and all possible hypotheses of the hardest cases) to the best 20% of the human breed doctors. And who knows what will happen beyond that?

Okay so who goes first? Me? Vinod? Your parents? Some poor unrepresented people in a poor nation (most likely)?

Let’s start with healthcare (or sickcare, as many knowledgeable people call it). Think about what happens when you visit a doctor. You have to physically go to the hospital or some office, where you wait (with no real predictability for how long), and then the nurse probably takes you in and checks your vitals. Only after all this does the doctor show up and, after some friendly banter, asks you to describe your own symptoms

Whilst I’ll agree this does happen in far too many places it’s not an example of best practice and it doesn’t happen in the worlds leading medical centres. The healthcare experience is a moving goal so at least try and reform what’s considered best practice rather than the worst example you can find.

For example in the practice of Dr John Bachman, Professor of Primary Care at the Mayo Clinic, patients access an interactive questionnaire technology via any secure web interface and this lets them effectively communicate with their Doctor providing their history securely before they go anywhere near a Doctors office. Armed with this important information their Doctor can then decide in advance of meeting what the best course of treatment is and how they’d like to manage that e.g in person or remotely. Dr Bachman MD has obviously also published an academic paper documenting the evidence he has that this works, it’s safe for patients and improves the quality and effectiveness of care and the details on this are already openly shared here.

…Sometimes a test or two may be ordered, if you can afford it. And, as we all know, most of the time, it turns out to be some routine diagnosis with a standard treatment

This highlights an assumption that is an all too common misunderstanding about the work of Doctors. Obviously nature dictates that the common things will present commonly in community medicine but the skill of a good family Doctor comes from being aware and alert to the uncommon symptoms of common causes and the common symptoms of uncommon causes.

some routine diagnosis with a standard treatment . . . something a computer algorithm could do if the treatment involved no harm, or at least do as well as the median doctor (I am not talking about the top 20% of doctors here—80% of doctors are below the “top 20%” but that is hard for people to intuit!)

I find it so humorous when I hear people talk about Doctors who are average, top 10%, etc, etc, as though there’s some well recognised talent bell curve and no one ever has a good/bad day. I wonder if they’ve ever seen a really talented Doctor working and begun to think about the range of subjective talents they have to employ with each and every different personality that they encounter?

I’m also really disappointed that Vinod didn’t expand upon all these effective treatments he knows about that involve no harm and how he thinks Dr A is going to ensure patients will comply with them.

Physically having to go to your doctor’s office makes sense for the most part, except that a lot of the basic tests are either visual (tongue and throat check) or auditory (listening to the breath and vibrations in the abdomen). Time plus cost will often discourage people from taking that first step to visit a doctor. Most of the time a Dr. A could at least advise you when it is worth visiting based on your normal body functions, your current indications, and your locality’s current infections and other symptom trends

Okay I can see some justification for this, it is after all what we do (with real Doctors) here at 3G Doctor. For informational problems this is a great way to manage patients but Dr Algorithm doesn’t yet exist so everyone who believes in this potential needs to be starting somewhere and that somewhere is where patients give their history and consultations are documented to their fullest extent.

A lot of the vitals being tested for (e.g. blood pressure, pulse) can now be routinely done at home or even with the help of an iPhone and an explosion of additional possibilities will emerge in the next decade

Okay so this is where it gets interesting. Yes vitals are cool but technologists need to be careful they don’t assume everything can be so easily quantified. Dismiss the power of listening to the patient and you’re going to miss out on most of what’s happening. This isn’t new infact the grandfather of modern medicine (Sir William Osler) told the world about it in the 19th century.

You are the one telling the doctor your symptoms. The doctor has to inquire (probably every time) into any possible history of each symptom, test results, and illnesses, except when he does not have time for you in that village in India

This is an outdated approach. One of the most respected primary care Doctors in the USA has recorded this video explaining why and outlining the simple solution that has already been scaled. Okay this leading innovation is not yet evenly distributed but it does also work in that village in India (where they have GSM access to the web).

The prescriptions are still done on paper, requiring you to, again, physically go to a pharmacy and pick up what you need there. So compliance is an issue

This isn’t true. Yes the future once again isn’t yet evenly distributed but there are plenty of Doctors and pharmacists using electronic prescribing even in the USA where since 2009 Medicare has encouraged adoption by clinicians through the provision of substantial financial support and the number of prescribers routing prescriptions electronically has continued to grow (from 156,000 (2009) to 234,000 (2010) and now nearly half of all US office-based prescribers). Of course competitive mHealth efforts by the big retail pharmacy chains in 2011 means this is now a rapidly expanding market eg. “refill RX by scan” apps from the likes of Walgreens

Looking at this, I cannot help but think that this is a completely antiquated system (regardless of whether it is healthcare or not)!

Get frustrated by all means but guess what there’s a lot of vested interests holding back change and the world is a very antiquated place. Before Dr A fixes all of healthcares woes I wonder if he’ll find time to fix the way the worlds most advanced economies continue to elect their representatives using ballot papers, make payments using cheque books, etc?

Going down the list, we find a pretty negative assessment. The vital signs could all be determined with the help of mobile devices, the operation of which do not require years of training and a certification

Really? Do you think registered Doctors would be happy to take the financial (never mind ethical) liability of authorising a patient to start a treatment based on a data point from a vital sign app?

You will be able to do this by yourself—Philips already is using the iPhone camera to try to measure vital indicators, others will be even more innovative and as an insurance company it would be cost-effective to give them to every insured person for free

I too love the Philips Vital Signs App for iPad 2 but there’s a big difference between “trying to measure” something and a quality diagnostic test that a Doctor (and his medical legal insurer) will be happy to base a diagnosis on.

I also find it funny that someone from a financial background is so confident that health insurers will find long term care of patients with devices like Apple iPad 2’s to be “cost-effective”. This suggests very little real world experience with health insurers.

Skin Scan is measuring your risk of skin cancer from a photograph of a skin lesion. Telemedicine is accelerating and a Qualcomm company is measuring heart rates using an iPhone. Cell phones that display your vital signs and take ultrasound images of your heart or abdomen are in the offing as well as genetic scans of malignant cells that match your cancer to the most effective treatment. Ear infection and skin rash pictures and more will all be mobile phone based, often supplemented by the kind of (fractal) analysis that Skin Scan does, and more than what the doctors naked eye could usually see

Yes there is no doubt that in the next decade we’ll see medical device convergence to the mobile phone but does this really mean we’re all going to get healthier? Consider the impact denial has on how we make bad diet and lifestyle choices and imagine you could use your mobile to show a smoker their “actual lung”. Do you really think this would be enough to have them stop lighting up or would they just continue to look away?

The history of symptoms, illnesses, and test results could be accessed, processed, and assessed by a computer to see any correlation or trends with the patient’s past. You are the one providing the doctor with the symptoms anyway after all!

Wow! I’d love to see Vinod’s ability to give a history to a Doctor. I’d be fascinated to find out how he thinks Veterinarians work.

I think it’s fair to suggest that there are things (that perhaps Vinod is unaware of) that even junior Doctors could diagnose from just reading this article.

Any follow-up hunts for clues could again be done with mobile devices

Which “hunts” shall we do? Surely if the mobile phone can do them all easily and cheaply we should do them all? What evidence is there that patients will want to participate in all these potentially invasive hunts? If the hunts find nothing will the patients that participate go away with a feeling that it’s just overkill and feel discouraged from participating next time?

The prescriptions—along with the medical records—could relocate to electronic and digital methods, saving paper, reducing bureaucracy, and easing the healing process

Progress in this area is happening for the last 20 years. It’s a change management problem.

If 90% of the time the doctor knows exactly the right kind of diagnosis from these very few and superficial inputs (we haven’t even considered genetics yet!), does it really require 10+ years of intense education for every diagnostician?

Any good Doctor will tell you they “know nothing exactly”. It’s important that we appreciate there’s a good bit of wait and see in good medical practice.

The fault is not entirely with the doctors, though. Most of us don’t know what set of symptoms warrant the full-scale attention of medical personnel, so we either go all the time or we do not go at all (save for emergencies). We also cannot realistically expect any (even our family) doctor to remember every single symptom and test result over the years, definitely not in a government hospital in China. Similarly, we cannot expect our doctor to be able to remember everything from medical school twenty years ago or memorize the whole Physicians Desk Reference (PDR) and to know everything from the latest research, and so on and so forth. This is why, every time I visit the doctor, I like to get a second opinion. I do my Internet research and feel much better

Participating in your care with your own use of information and resources is key to how healthcare is going to increasingly work in the future.

Imagine how much more powerful this can be if your Doctor was providing you with comprehensive documentation of the consultation including all the answers you gave in your interactive patient history questionnaire (restructured so that it’s comprehensible), all the additional important bits of history the Doctor could pick up from the consultation, their written advice and an action plan for you going forward with some links to quality online resources where you could start your internet research?

But I always wonder why I cannot input my specific test numbers and have a system offer me a “second opinion” on the diagnosis since it has all the data that the doctor has and can use all my current and historical data effectively

This is a common misunderstanding of what a good Doctor does. Much of the important history a Doctor takes is not distinct and it’s not documented. Sometimes it can be your attire, mannerisms, something you say in “passing” conversation, your timeliness, etc, etc.

Even the worlds best EHR’s are never very accurate as an example imagine you could access every single NHS patient record (a product of $22 billion of government spending) how many do you think would say the patient uses cocaine? I’m willing to bet it’s not even a small percentage of the 1 million that the United Nations office on Drugs and Crime has estimated use the illegal drug in the UK. I wonder how Vinod would suggest such patients go about openly sharing such important, but also incriminating, information in their government operated EHR?

In fact, it is not hard to imagine it having more data than the doctor has since my full patient record would be at the tip of its digital brain, unlike the average doctor who probably doesn’t remember my blood glucose levels or my ferritin from two years ago. He does not remember all the complex correlations from med school in which ferritin matters—there are three thousand or more metabolic pathways, I was once told, in the human body and they impact each other in very complex ways. These tasks are perfect for a computer to model as “systems biology” researchers are trying to do

Let me see the evidence first okay?

Add to it my baseline numbers from when I was not sick, which most doctors don’t have and if they did 80% of physicians would be too lazy to use or not know how to use

It always struck me that the saving lives caper is precisely the type of occupation that attracts the bone idle and stupid. Probably more like 90% though! 😉

Applied Proteomics can extract tens of gigabytes of proteomics—what my genes are actually doing instead of what they can do—baseline data from one drop of blood. Oh, by the way I have my 23andMe data to add my genetic propensities (howsoever imprecise today, but improving rapidly with time and more data)

Not sure about you but 10GB of “imprecise” data is enough to start frightening me.

The doctor uses a lot of imprecise judgments too as most good doctors will readily admit. My very good doctor did not check that I have relative insensitivity, genetically, to Metformin, a diabetes drug. It is easy to input the PDR (the Physicians Desk Reference), the massively thick, small-font book that all physicians are supposed to know backwards and forwards. They often don’t remember everything they read, in med school but it is a piece of cake for computers. The book on your typical doctor’s desk is probably not current on the leading-edge science either

It’s definitely not the leading edge. PDR has been available on mobile devices for sometime now and is much safer (unlike the printed book it can be edited, updated over the air, always carried, etc).

Confirmed science and emerging science are different things and each has a role. Doctors mostly use confirmed science, the average doctor not understanding and pros and cons of each or the expected value of a treatment (benefit and harm). And our 18th century tradition of “first do no harm” dictates that if a treatment hurts ten patients a year but saves a thousand lives we reject it

Of course it’s critical we have rejection of harmful medicine (or we’re just ditching science in favour of a big game of 1/100 russian roulette) but Vinod’s claim is factually inaccurate as there is plenty of evidence to support the fact that modern medicine doesn’t completely reject things that have been proven harmful eg. most drugs are discovered as a result of their side effects and drugs like Thalidomide are again being prescribed despite the horrendous impact it had on thousands of lives.

With enough examples, today’s techniques for language translation (or newer techniques) can translate from human lingo for symptoms (“I feel itchy” or “buzzy” or “reddish bubbly rash with pimples” or “less energy in the morning” or “sort of a stretch in my tendon” and the myriad of imprecise ways symptoms are described and results interpreted — these are highly amenable to big data analysis) into medical lingo matching the PDR

Can’t wait to see this working.

With easy input of real medical results into a computer and long-standing historical data per patient and per population, which a human cannot possibly handle, and patient and population genetics, I suspect getting a second opinion of my diagnosis from Dr. A is a reasonable expectation, and it should certainly be better than a middling physician’s (especially in less developed countries like India, where there is a dire shortage of trained physicians)

I can’t help but think this is a very “ditch the baby with the bathwater approach”. Perhaps Vinod should consider the idea of empowering those same middling physicians with these amazing algorithms?

I may still need a surgeon (though robotic surgeons like those from Intuitive Surgical are on the way too)

As good as Vinod thinks Dr A’s going to be he’s not too sure he’ll be able to keep us safe from the butchers knife.

or other specialists for some tasks for a little while and the software may move from “second opinion” (in three years? Or seven?) to “bionic software” for the physicians (in five or ten years, with enough patient data?). Bionic software, again, defined here as software which augments and amplifies human understanding

I think Vinod should take a look at the decision support tools that modern Doctors already use, he might be surprised to find this road is already being walked…

But I doubt very much if within 10-15 years (given continued investment and innovation and keeping the AMA from quashing such efforts politically) I won’t be able to ask Siri’s great great grandchild (Version 9.0?) for an opinion far more accurate than the one I get today from the average physician

No surprise that it’s the AMA that’s stopping this all happening (even though it only has an impact on a small minority of the worlds Doctors). Vinod might also want to check out the history of Siri as I’ll bet he’ll be surprised to learn it didn’t fall from the sky but is itself the great great great grandchild of over 30 years of R&D.

Instead of asking Siri 9.0, “I feel like sushi” or “where can I dispose a body” (try it…it’s fairly accurate!) and with your iPhone X or Android Y with all the power of IBM’s current Watson computer in the mobile phone and an even more powerful “Nvidia times 10-100” server which will cost far less than med school with terabytes or petabytes of data on hundreds of millions (billions?) of patients, including their complete genomics and proteomics (each sample costing about the same as a typical blood test)

No doubt the future will provide us with this capacity but I think once we get to this stage the interactions will be the other way around eg. instead of us asking the mobile it will be telling us before we noticed anything.

IBM’s Watson computer, I understand, is now being applied to medical diagnosis after handling imprecise and vague tasks like winning at Jeopardy, which experts a few years ago would have said could not be done. “Computers cannot match the judgment of humans on these kinds of tasks!” And with enough data, medical diagnosis or 90% of it is an easier task than Jeopardy

It’s interesting there’s no mention about who’ll pay for all this magic or if patients are going to be okay with their healthcare providers or insurers having complete access to their digital lives.

Already Kaiser Permanent already has 10 million real-time medical records with details of 30,000,000 e-visits last year with caregivers and computer modeling of key diseases per individual that data scientists would love to get their hand on

I bet they would. I can also imagine a few marketing firms might also like to share in this. Has anyone asked the patients if it’ll be okay??

Already, according to IDC 14% of the US population is using their phones for medical help and 200 million health and fitness related mobile applications have been downloaded according to pyramid research. Fun stuff, though early. They are probably two generations away from systems that are actually useful

I think these statistics widely discount the use of mobiles. Maybe only 14% have actually called 911 or their Doctor with their mobile but I bet the rest would all do it if they had the need eg. they encountered a medical emergency, suddenly fell ill, etc

…My UP wristband or something like it (disclosure: I am an investor in Jawbone)) will know all my sleep patterns when I am healthy and how many steps I take each day and may have more data on my mobility if I ever get depressed than any psychiatrist ever will know what to do with

A lot of this could be done without the need for a bracelet, perhaps it would be easier just to share our Facebook passwords too?

Within a few years, my band will know my heart rate at all times, my respiration rate, my galvanic skin resistance (one parameter among multiple ones used to measure my stress level), my metabolic rate (should cost about $10 to add to the band by measuring my CO2 in my breath and may detect changes in my body chemistry too like when I get a certain type of cancer and traces of it show up in my breath)

Projecting myself forward I’m getting the feeling that Vinod isn’t going to get the chance to read emails in the future. Perhaps he’ll be too busy reading vital signs or taking days off to get full body scans as each ketone in his breath is quantified.

All my “health data” as well as my “sick data” and my “activity data” will be accessible to Dr. A (and location when I was stressed or breathing hard or getting the allergic reaction and what chemicals were nearby or in the air—did toluene exposure cause me to break out in a rash from that new carpet or trigger a systemic reaction from my body?)

The world doesn’t yet buy simple connected safety equipment like connected smoke alarms and Vinod’s talking about lawsuits against carpet manufacturers. Only in America hey?

I doubt I will be prescribed an arthritis medicine without Dr. A knowing my genetics and the genetics of my autoimmune disease

Unless you’re insurer is paying for Dr A and your medicines, in which case you’re likely to get the cheaper generic drug regardless of the marginal benefit (don’t worry Dr A’s so smart you’ll never be wise to this little trick).

Or a cancer medicine without the genetics of my cancer when the genetic sequence (once per life) costs far less than a single dose of medicine

I take it there’s a way to stop the pharma firms from influencing the programmers of Dr A.

In fact all my infectious disease treatments may be based on analysis of my full genome and my history of exposure to viruses, bacteria and toxic chemicals

Unless of course like a lot of people your disease has nothing to do with your genome and everything to do with lifestyle choices you make?

Constant everyday health data from non-medical devices will swamp the “sickness tests” used in most medical diagnosis and be supplemented by detailed genetic, proteomic and sick data with bionic software and machine learning systems

Remember the story about the little boy who cried wolf? In Vinods future we’ll probably tell bedtime stories to our grandchildren about the little mobile that kept pestering us to go for a walk and put down that soda. In the scramble to create a mobile that will nag us into taking better healthcare decisions I think a lot of people are overlooking the technical counter argument and the fact that individuals will still want to make their own decisions and will resist policing of these in the same way that they already ignore healthy practices.

If I’m completely wrong about this I’m pretty sure the quantified health movement will sooner or later reach it’s logical outcome and the mobiles will decide they’re better off without us…

Siri might even remind me one day that my heart rate while sleeping has gone up abnormally over the last year, so I should go run some heart sickness cardiograms or imaging tests

Why wait a year? I thought Dr A was going to be data munching everyones heart rate? Take this any further and it might start deciding to wake you up at 430am for a morning swim (with an exciting Groupon offer of course!).

Obviously, Siri’s children and its server friends will be able to keep up with the latest research and decide on optimal strategies based on patient preference

I’d guess that about 98% of the population is going to decide they want to take their chances and make their own choices in life.

(“I prefer to live longer even if it means all the fancy treatments” or “I want to live a normal life and die. I prefer to spend more of my time with my children than at the hospital” or “I like taking risky treatments”)

I presume that if you tick the last box you can expect much higher health insurance premiums?

My best guess is that today a physician’s bias makes all these personal decisions for patients in a majority of the cases without the patient (or sometimes even the physician) realizing what “preferences “ are being incorporated into their recommendations. The situation gets worse the less educated or economically less well-off the patient is, such as in developing countries, in my estimation

I see no mention that all of this is going to be open source so I take it big government and it’s backers can calculate everything so that no one knows what “preferences are being incorporated into their recommendations”. I bet that’ll attract more than the 0.13% that made any effort to use the UK’s patient accessible NHS record service.

In my estimation in “more” educated or better-off populations we have the reverse. Compare America’s thinking on birth control with that of Senegal or look to neighboring Cuba where you have some of the best access to healthcare and think about how this compares with the affluent USA where healthcare costs are the leading cause of personal bankruptcy.

I also think the “less educated” excuse is a red herring as in markets where there is apparently “more educated” patients and higher use of the internet you’ll also find much higher levels of misinformation, unnecessary treatments, etc.

Envisioning Future Healthcare. Eventually, we won’t need the average doctor and will have much better and cheaper care for 90-99% of our medical needs

Obviously this presumes someones actually got an average Doctor. Whilst patients may rate their healthcare system low they all highly rate the Doctor they have a personal relationship with.

Hopefully Vinod’s utopia will arrive soon because the aging population and current shortage of Doctors will ensure any freed up capacity will be quickly redirected.

We will still need to leverage the top 10 or 20% of doctors (at least for the next two decades) to help that bionic software get better at diagnosis. So a world mostly without doctors (at least average ones) is not only not reasonable, but also more likely than not. There will be exceptions, and plenty of stories around these exceptions, but what I am talking about will most likely be the rule and doctors may be the exception rather than the other way around

Surprisingly I don’t think Vinod understands what “average” means. I bet it would amaze him to learn that if you shot all the doctors who weren’t in the top 10% you’d still have “average Doctors” and 50% of them would still be “below average”.

However fictionalized, we will be aiming to produce doctors like Gregory House who solve biomedical puzzles beyond our best input ability. And India, China and other countries may not have to worry about the investment in massive healthcare or massive inequalities in the type of physicians they might have access to. And hopefully our bionic software (or independent software someday) will be free of the influence of heavily marketed but only minimally effective drugs or treatment regimes or branding campaigns against generics or lower-cost and equally effective, more affordable drugs and treatments

I wonder if Vinod realises that patients in many parts of the world don’t even have access to many of the webpages he’s capable of viewing in the USA?

Dr. A will be able to do a cost optimization too both at the patient level and at the policy level (but we may choose, at least for a decade or two, to reject its recommendations—we will still be free to be stupid or political)

Why is the grass always greener in the future?

What is important to realize is how medical education and the medical profession will change toward the better as a result of these trends. The vision I am proposing here, though, is one in which those decades of learning and experience are used where they actually matter. We consider doctors some of the most learned people in our society. We should aim to use their time and knowledge in the most efficient manner possible. And everybody should have access to the skills of the very best ones instead of only having access to the average doctor

Oh dear. Definition of average = the sum of numbers divided by n.

And the not so “Dr. House’ doctors will help us with better patient skills, bedside manners, empathy, advice and caring, and they will have more time for that too

This should stop an overnight exodus from the profession but perhaps some will consider jobs as VC’s – or will “VC Algorithm” wipe out the existence of that handy little profession too?

Summary:

The simple answer to the initial question is neither. We need Doctors to use all the effective tools at their disposal (including algorithms) to provide patients with documented care and we need to ethically use this collective information to improve our understanding of medicine and improve the health of others.

To move forward instead of reinvention let’s keep building on the best practice and lessons from those who are more experienced in this subject area than ourselves (yes even the ones who are only “average”!).

Unfortunately I get the feeling Vinod’s going to be disappointed in his hunt for the ‘facebook of healthcare’ because it’s like he’s trying to conceptualize the automobile of the future by analysing what’s wrong with the Model T.

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8 Responses to Do we need Doctors or Algorithms?

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