The End of Medicine: How Silicon Valley (and Naked Mice) Will Reboot Your Doctor


A Must read book to discover how are technology answers to the galloping cost increases of Healthcare.



Most Important Notes

·        Doctors are good with Memorization.

·        Chapter 6 – nice history of healthcare.

·        Rational Drug design doesn’t exist (yet).

·        Chapter 20- use of neural networks for pattern recognition.

Personalities

Name

Notes

Contribution

Lindon Johnson

Ultimate politician, Created Medicare Free care for people 65 and up; .Trying to buy senior vote in next elections.

Help the poor pay doctors’ bills

Ray Kurzweil

Idea of singularity coming

A terrific presentation of singularity coming and lots of insight about the whole range of technology; pg248

Dr. Blake

Chapter 6

Talk about the sickest Medicare beneficiaries

Wilhelm

German Physics professor; 1895

Discovering X rays.

Dr. Goldman

256 slice machine

Heart scan in not much more than 10 seconds.

Lee Hartwell

Noble Prize in 2001

Cancer development in yeast

Henry Adams

Book: The Educational of Henry Adams: exponential graphs about the doubling index of worldwide energy consumption, which he took as a proxy for the advance of civilizations and technology.

The law of accretion of progress

Carver Mead

Book: Collective Electrodynamics

A basic principle- if you can build it, you can understand it.


Institutions

·        Department of Health and Human Services Center for Medicare and Medicaid Services; pg 151

·        Federal Communications Commission ( FCC ), pg 230

·        Manhattan Diagnostic Radiology, pg 184

·        Quest Diagnostics, pg 48

 

Chapter

Comments

4 What the hell am I doing here?

·   Because of new technology entire careers disappear like trolley car conductors of old. Were doctors next? The author hoped so.

·   The author had listened plenty of pitches for the latest miracle drug or medical device. But every time he looked at health care, costs were going up, not down.

·   One by one, industries are being democratized. Power is shifting from producers and service providers to users..

·   Power to the people-everywhere except medicine.

·   Find where health care scales, find some new market that doesn’t just enhance our life search engines or HDTV or Smartphones, but actually saves it.

5 Echo/ Nuclear

 

·  $1.8 trillion is spending: 15% of GPD: third for hospital expenses, third for doctors and clinical services, and quarter for drugs and 10% for nursing home and in-home care.

·  Individuals reaching -16% of spending, private health insurance and other private funds pay for 40%, the government to pick up the remaining 44%. It’s 33% feds and 11% states.

·   That’s $ 5 400 /year/ person. In England $ 2000 /person.

·  Cost distribution/ disease: 70% of $500 billion $1.8 trillion is spent on chronic disease. $210 billion was spent last year on cardio and stroke, $192 billion on cancer, $75 billion on obesity-related illnesses, $92 billion on diabetes and $22 billion on arthritis.

·  Some think life expectancy is now increasing one additional year for every four years that pass.

6 Do Doctors Scale?

Nice health care history lesson

·   Today doctors get the status, but no longer the wealth.

·   Wage controls innocently put in place during World War 2 forced employers to come up with something to attract workers. untaxed compensation.

·   Managed care became the corporate buzzword. Insurers said “You can have whatever health care you want, as long it’s on our approved list.”

·   Faceless administrators, random doctors, long waits, rationing of limited resources-it felt like the Moscow plan.

·   Productivity became the buzzword.

·   Doctors are a proud a bunch-it’s not about the money. It is about the patient. Doctors will do everything they can for their patients to make them better. It’s that Hippocratic Oath they take: I swear by Apollo Physician and Asclepius and Hygieia and Panaceia and all the gods and goddesses…

·   5 % of the sickest Medicare beneficiaries accounted for 47% of Medicare expenditures in 2002.

·   Dr. Blake said: “Why is that? Anyone, anyone?” and then he started shouting, “Because they have the toys-imagers, scanners, whatever. Anyone with toys breaks out of that pay-per-15-minute-consultation quagmire.”

·   It’s all about the toys.

·   Doctors are going to do procedures that they can get reimbursed for. There are codes for echoes and nukes.

·   Cancer now has the top shot. 476,009 cancer deaths and only 450,637 from heart disease.

·   Doctors are pretty good at memorization.

·   Just keep people from getting sick in the first place.

7 Zap It Out

·     Jeffrey Immelt, the CEI of General Electric

·     Erich Reinhardt of Siemens Medical

·     Medical imaging

·     There in not a single cancer that is truly resistant to radiation. If we can find it early enough, we can eradicate it.

8 Blood Tests

·     Blood tests are probably the biggest scam going in medicine.

·     Pretty smart- give the razor, sell the blades.

·     Each checks mark on the form is another$ 25 to $ 50 for a nickel

·     Molecular diagnostics-DNA tests

9 Cave

·     A scientist can study these models and then invent proteins that fit perfectly into the shape and folds of the cancer cell. This is- rational drug design.

10 Lasik

·     Lasik stands for laser in situ keratomileusis; blast high energy coherent light, but only into the cornea.

·     A new piece of technology in the hands of a specialized doctor could mean literally dozens of other doctors out of a job- the bank tellers of a new era.

11 The Big Three

·     Heart

·     Stroke

·     Cancer

13 Meeting Gary Glazer

·     The economy is nothing more than a mechanism to increase the standard of living if its participants. Period. End of story. The rest is noise. You happen to be following a business that contributes to productivity and can help economy grow and wealth be created. Other things like health care, well…that’s what we spend our newfound wealth on.

·     Lukas Center

14 The dish

·     A six-hour flight is like having a few X rays.

·     The protons of hydrogen are distributed differently in different tissue types.

20 Rad or CAD

·     One out of 25 recalled. One out if 250 is actual cancer.

·     Here was a piece of technology that not only augments doctors but potentially replaces them.

·     You can get away with anything in the military.

·     Neural networks.

·     40 million mammograms, 200,000 cases of breast cancer.

·     We can find nodules in the lung.

21 Doctors Out

·     We don’t need and probably can’t afford doctors as the front line of defense anymore.

·     There’s a huge difference between medicine and the real world.

·     Medicine is a service business.

·     Like it or not, you are the product, no the consumer.

22 3-D

·     GE makes CT scanners. OS do Philips, Siemens and Toshiba.

·     Something is new and exciting, it is probably within a 15-mile radius of downtown Palo Alto.

25 Genetic Tests

·     The author wondered if genetic test were any good.

26Do You Happen to Have a Syringe?

·     Wail-in diagnostic centers scattered around the U.S. I pulled up a list from both Quest and LabCorp, typesd in my zip code, and found one less than a mile away.

·     The self-serve  economy is not allowing people to go in

27 GeneChip-That Counts, Right?

·     More of an array. In fact, the industry refers to it as a microarray. The funny thing is, the GeneChip follows its own Moore’s law.

·     Cool liquid handling robotics- LabChip.

·     To extract value from the genome requires an analog expertise, drug discovery processes, diagnostics, whatever…not Craig’s digital DNA expertise.

·     The one gene, one protein, dogma has been replaced with something a lot more complicated and a lot less understood. It will need digital technology, stuff that scales. Then it will settle out.

28 Who Pays?

·     Every possible procedure is spelled out in excruciating detail at the Department of Health and Human Services Center for Medicare and Medicaid Services, with prices set by some bureaucrat who probably flunked out of community college.

29 Can Biotech Deliver?

·     That sounded more like trying to buy up every Willy Wonka chocolate bar to find the golden ticket.

·     Large molecules drugs can’t get across cell membranes, and as protein, are metabolized the same way the protein in a burger is, and therefore need to be injected instead of taken in pill form, which drops the available market by a factor pf 10, maybe 100.

30 Monoclonal Antibodies

·     Each cancer has unique proteins associated with it.

·     Antibodies are proteins that our immune systems produce to fight anything foreign in our bodies that could kill us- viruses, bacteria, toxins and even other proteins.

·     Mice reproduce like rabbits, don’ take up much space and don’t have a hell of a lot else to do. Sure they all want to grow up to be rats and live in the New York Subway system, but don’t we all.

·     $ 270 million invested over 19 years and clinics can hope, pray for one new drug per  year.

·     The antibodies produced are called monoclonal.

32 Angio

·     It takes hundreds of iterations and lots of capital to turn the innovation into a real product.

·     Simpson’s Roto-Rooter is one of many attempts. An Isreali company named InSightec has a technology they call MRgFUS.

·     It won’t work and change medicine by itself. It needs the back end, the cleanup, to get cheaper,too.

33 256 Slice

·     With 256 slices we will be able to scan the entire heart in 400 milliseconds. That’s amazing- that’s half a rotation. It ‘s not the temporal resolution, it’s that we can do it in less than one beat of the heart. No blurs. Plus we can check on things like perfusion-functional decreases in blood flow.

34 Physical of the Future

·     Measuring cholesterol and blood pressure is like reading the outside temperature and humidity from inside your house and guessing if it’s raining.

·     Today it is cheaper for our symptoms to show up in real life- clutching chest, can’t breathe, life flashing in front of your eyes- than in a few gigs of a virtual scan.

·     Maybe in some ways Darwinian- you become dependent on your own research and effort. It’s going to take some combination of personality, character and intelligence just to be able to handle it- fight back the nausea when someone shows you your guts and glory.

·     With 256 slice machine a lot of hospital beds and cardiologist and nurses with nothing to do. But that’s exactly what is going to happen as scanning gets cheap enough., as Dr. Goldman’s 256-slice machine gets utilized 24/7. He is the antihospital, antidoctor doctor.

36 Quadrus

·     Molecular imaging is the next step. That’s what we are working on.

·     A 10-millimeter tumor has around 1 billion cancer cells in it.

·     Today we are just imaging structure. Over next five years or so, in humans anyway, we will get to a temporal resolution of a couple of hundred microns. We will be able to image any named vessel in the body. It will generate more info than the Human Genome Project.

·     It’s got to be 10 to 15 millimeters wide before you can make it out in soft tissue. It’s that billion-cell tumor, which,  by you see it, it’s probably already deadly.

·     Problems occur internal to the cell long before structural changes happen.

·     Nothing works 100%

·     It’s the only imaging biomarker approved.

·     The theory behind PET scans-positron emission tomography.

·     Any PTE scanning setup also has to own their very own cyclotron- that’s right, a particle accelerator.

·     Fluorine- 18 has a half-life of 110 minutes, carbon-11, 20 minutes and nitrogen-12 about 10.

39 Med Conference

·     Explanation of Bio Market, pg, 220

40 Cancer Panel

·     The more precisely the gene is knows, the less precisely its effects will be know in this instant.

·     Vioxx was a wonder drug until it got over prescribed and some patients started having heart attacks and strokes.

41 Listwin at Buck’s

·     Funny expression- Khaki patrol

·     The FDA is like FCC, Big Pharma like the regional Bells.

·     Lee Hartwell, the Nobel Prize in 2001for figuring out how cancer develops in yeast. He’s attracted a lot of smart people. He gets early detection.

·      The keys are biomarkers.

·     Over simplifying, each tumor will express a unique protein, and if you can test for that protein, you may have a biomarker.

·     There are millions of proteins- we probably know about 5,000 of them.

·     No one really wants to invest in doctors, but they do want to invest to intellectual property.

·     What if the spending was on detection instead of invention? Medicare becomes health monitoring

42 Lighting up

·     Debates rage whether mammograms are effective, let alone cost effective.

·     A couple of billion dollars is spent on mammograms, plus all the mental anguish of false positives and risk from biopsies, all to find 200,000 cases of breast cancer.

43 Silicon and Biology

·     Quantum theory makes things get bigger rather then smaller. Quantum effects are not restricted to atoms as people believe but rather reach out across the universe and have a fascinating interplay with thermodynamic effects.

·     Physics uber alles- physics prevails and the reduction of chemistry and biology to physics.

·     It is impossible to reduce in principle- mathematically impossible to reduce biology to physics.

·     We have reached the point already where electronics and biology work together. This was nothing new.

·     Carver Mead in his book’ Collective Electrodynamics’ describes a principle : if you can build it, you can understand it. That’s why engineers- why Silicon Valley- out- innovates the academic scientists. They actually build things

·     Impinge, a company, with a device a s few square millimeters- essentially a grain of sand that is powered by the incident radiations from the reader. And it ahs to sell, not for $700 but for four to eight cents apiece. This is a kind of real innovation that reflects the ingenuity that can be unleashed by effort to mimic biology.

·     Interplay of biology with silicon.

·     Perhaps electrons and biology were going to collide sooner than author thought.

46 Hartwell

·     We have to just to shift the curve, become less reliant on drugs. Early intervention has a high hurdle,- the right way to go.