Theranos and the Future of Diagnostic Medicine

Elizabeth Holmes is a 29-year-old chemical and electrical engineer and entrepreneur who dropped out of Stanford as an undergraduate after founding a life sciences company called Theranos in 2003. Her inventions, which she is discussing in detail for the first time in this Wall Street Journal interview, could upend the industry of laboratory testing and might change the way we detect and treat diseases:

The secret that hundreds of employees are now refining involves devices that automate and miniaturize more than 1,000 laboratory tests, from routine blood work to advanced genetic analyses. Theranos’s processes are faster, cheaper and more accurate than the conventional methods and require only microscopic blood volumes, not vial after vial of the stuff. The experience will be revelatory to anyone familiar with current practices, which often seem like medicine by Bram Stoker.

This is the future of diagnostic medicine. Theranos’s technology will eliminate multiple lab trips because it can “run any combination of tests, including sets of follow-on tests,” at once, quickly, and with just one microsample.

A microsam

A microsample of blood used by Theranos

Another goal is transparency:

Ms. Holmes says her larger goal is increasing access to testing, including among the uninsured, though she might also have a market-share land grab in mind. For instance, she says Theranos will publish all its retail prices on its website. The company’s X-ray of self-transparency also includes reporting its margins-of-error variations online and on test results and order forms, which few if any labs do now.

Worth the read. Don’t miss who’s on the board of directors of Theranos: Henry Kissinger, Sam Nunn (ex-senator from Georgia), and Richard Kovacevich (who served as the CEO of Wells Fargo & Company).

Invisible Gorillas in Medicine

You may be familiar with the Invisible Gorilla phenomenon, a case for “inattentional blindness” when we are focusing on something intently and miss something else entirely. The most famous version is this video in which the narrator asks the viewer to count the number of basketball passes made, while a gorilla walks by in the background…

Now, a new study from psychological scientists at Brigham and Women’s Hospital in Boston showed that 83 percent of radiologists failed to spot the animal in a CT scan, even though they went past it four times on average:

Three psychological scientists at Brigham and Women’s Hospital in Boston—Trafton Drew, Melissa Vo and Jeremy Wolfe—wondered if expert observers are also subject to this perceptual blindness. The subjects in the classic study were “naïve”—untrained in any particular domain of expertise and performing a task nobody does in real life. But what about highly trained professionals who make their living doing specialized kinds of observations? The scientists set out to explore this, and in an area of great importance to many people—cancer diagnosis.

Radiologists are physicians with special advanced training in reading various pictures of the body—not just the one-shot X-rays of the past but complex MRI, CT and PET scans as well. In looking for signs of lung cancer, for example, radiologists examine hundreds of ultra-thin CT images of a single patient’s lungs, looking for tiny white nodules that warn of cancer. It’s these expert observers that the Brigham and Women’s scientists chose to study.

They recruited 24 experienced and credentialed radiologists—and a comparable group of naïve volunteers. They tracked their eye movements as they examined five patients’ CT scans, each made up of hundreds of images of lung tissue. Each case had about ten nodules hiding somewhere in the scans, and the radiologists were instructed to click on these nodules with a mouse. On the final case, the scientists inserted a tiny image of a gorilla (an homage to the original work) into the lung. They wanted to see if the radiologists, focused on the telltale nodules, would be blind to the easily detectable and highly anomalous gorilla.

The gorilla was miniscule, but huge compared to the nodules. It was about the size of a box of matches—or 48 times the size of a typical nodule. It faded in and out—becoming more, then less opaque—over a sequence of five images.  There was no mistaking the gorilla: If someone pointed it out on the lung scan and asked, What is that? – everyone would answer: That’s a gorilla.

The gorilla seems hard to miss (photo here).  I think the idea behind this experiment was to determine whether being highly trained made people less susceptible to the phenomenon of change blindness. Doesn’t seem to be the case based on the results of this study.

The Five Types of Laughter

Haha. Colin Nissan’s piece “The Gift of Laughter” in The New Yorker made me chortle:

Laughing triggers the release of chemicals in your brain, creating feelings of happiness that can often linger long enough for someone to set off your singing trout plaque again. There’s such a strong belief in the medical benefits of laughter that scientists created a gas out of it—one that millions of dentists successfully administer each year to ease their patients’ discomfort during above-the-clothes fondling.

Laughter has proven to be useful in other ways, too. It can make an awkward silence a lot less awkward, like when you’re in a terrible marriage or an elevator. We have laughter to thank for our unique human ability to laugh at ourselves, and, more important, at people with cell-phone holsters. And what would tickling be like without laughter? It would be like trying to tickle a bunch of unticklish people, and if you’ve ever wiggled your fingers across one of them, it’s a goddam nightmare.

There are five types of laughter to choose from. You can giggle, chuckle, howl, chortle, and, in extreme cases when you’re wearing a monocle, even guffaw. Assess the situation and carefully decide which type is appropriate, because the wrong laughter can send the wrong signals and encourage your boss to keep doing his Arnold Schwarzenegger impression.

The ending is kind of weak, but the beginning and middle are LOL-worthy.

(hat tip: Chris Sacca)

A Doctor’s Experience With the Afterlife

Newsweek has published a first person account from a neurosurgeon, Dr. Eben Alexander, who found himself in a coma and experienced a journey to the afterlife. Taking this with a grain of salt. I liked the vivid imagery, however:

A sound, huge and booming like a glorious chant, came down from above, and I wondered if the winged beings were producing it. Again, thinking about it later, it occurred to me that the joy of these creatures, as they soared along, was such that they had to make this noise—that if the joy didn’t come out of them this way then they would simply not otherwise be able to contain it. The sound was palpable and almost material, like a rain that you can feel on your skin but doesn’t get you wet.

Seeing and hearing were not separate in this place where I now was. I could hear the visual beauty of the silvery bodies of those scintillating beings above, and I could see the surging, joyful perfection of what they sang. It seemed that you could not look at or listen to anything in this world without becoming a part of it—without joining with it in some mysterious way. Again, from my present perspective, I would suggest that you couldn’t look at anything in that world at all, for the word “at” itself implies a separation that did not exist there. Everything was distinct, yet everything was also a part of everything else, like the rich and intermingled designs on a Persian carpet … or a butterfly’s wing.

It gets stranger still. For most of my journey, someone else was with me. A woman. She was young, and I remember what she looked like in complete detail. She had high cheekbones and deep-blue eyes. Golden brown tresses framed her lovely face. When first I saw her, we were riding along together on an intricately patterned surface, which after a moment I recognized as the wing of a butterfly. In fact, millions of butterflies were all around us—vast fluttering waves of them, dipping down into the woods and coming back up around us again. It was a river of life and color, moving through the air. The woman’s outfit was simple, like a peasant’s, but its colors—powder blue, indigo, and pastel orange-peach—had the same overwhelming, super-vivid aliveness that everything else had. She looked at me with a look that, if you saw it for five seconds, would make your whole life up to that point worth living, no matter what had happened in it so far. It was not a romantic look. It was not a look of friendship. It was a look that was somehow beyond all these, beyond all the different compartments of love we have down here on earth. It was something higher, holding all those other kinds of love within itself while at the same time being much bigger than all of them.

Without using any words, she spoke to me. The message went through me like a wind, and I instantly understood that it was true. I knew so in the same way that I knew that the world around us was real—was not some fantasy, passing and insubstantial.

The message had three parts, and if I had to translate them into earthly language, I’d say they ran something like this:

“You are loved and cherished, dearly, forever.”“You have nothing to fear.”

“There is nothing you can do wrong.”

Lots of dissenting opinions in the comments, obviously.

On Medical Errors in Hospitals

This is a terrifying read from Marty Makary, a surgeon at Johns Hopkins Hospital, in The Wall Street Journal. Medical errors kill enough people to fill four jumbo jets a week:

I encountered the disturbing closed-door culture of American medicine on my very first day as a student at one of Harvard Medical School’s prestigious affiliated teaching hospitals. Wearing a new white medical coat that was still creased from its packaging, I walked the halls marveling at the portraits of doctors past and present. On rounds that day, members of my resident team repeatedly referred to one well-known surgeon as “Dr. Hodad.” I hadn’t heard of a surgeon by that name. Finally, I inquired. “Hodad,” it turned out, was a nickname. A fellow student whispered: “It stands for Hands of Death and Destruction.”

He then offers five suggestions for improvements, including the use of video recording of surgeries:

Cameras are already being used in health care, but usually no video is made. Reviewing tapes of cardiac catheterizations, arthroscopic surgery and other procedures could be used for peer-based quality improvement. Video would also serve as a more substantive record for future doctors. The notes in a patient’s chart are often short, and they can’t capture a procedure the way a video can.

Medical Tourism in America

From John C. Goodman’s new book, Priceless: Curing the Healthcare Crisis, we learn that there is, in fact, a medical tourism market in the United States. In fact, even Americans can partake in it:

Moreover, you do not have to be a foreigner to benefit from domestic medical tourism. Colorado-based BridgeHealth International offers US employer plans a specialty network with flat fees for surgeries paid in advance that are 15 percent to 50 percent less than a typical network. North American Surgery, Inc., has negotiated deep discounts with 22 surgery centers, hospitals and clinics across the United States as an alternative to foreign travel for low-cost surgeries. As noted, the “cash” price for a hip replacement in the network is $16,000 to $19,000, making it competitive with facilities in India and Singapore.

One reason why so little is known about the domestic medical tourism market is that hospitals prefer that most of their patients not know about it. The reason: they are often offering the traveling patient package prices not available to local patients. That occurs because the hospital is only competing on price for the patients who travel.

(via Alex Tabarrok)

Why Healthcare in America Is So Expensive

In his latest post for The Washington Post, Ezra Klein compares the cost of healthcare procedures in the United States to that in France, Britain, Canada, and India. The obvious answer why healthcare is so expensive in America is that the prices are higher.

On Friday, the International Federation of Health Plans — a global insurance trade association that includes more than 100 insurers in 25 countries — released more direct evidence. It surveyed its members on the prices paid for 23 medical services and products in different countries, asking after everything from a routine doctor’s visit to a dose of Lipitor to coronary bypass surgery. And in 22 of 23 cases, Americans are paying higher prices than residents of other developed countries. Usually, we’re paying quite a bit more. The exception is cataract surgery, which appears to be costlier in Switzerland, though cheaper everywhere else.

Prices don’t explain all of the difference between America and other countries. But they do explain a big chunk of it. The question, of course, is why Americans pay such high prices — and why we haven’t done anything about it.

“Other countries negotiate very aggressively with the providers and set rates that are much lower than we do,” Anderson says. They do this in one of two ways. In countries such as Canada and Britain, prices are set by the government. In others, such as Germany and Japan, they’re set by providers and insurers sitting in a room and coming to an agreement, with the government stepping in to set prices if they fail.

In America, Medicare and Medicaid negotiate prices on behalf of their tens of millions of members and, not coincidentally, purchase care at a substantial markdown from the commercial average. But outside that, it’s a free-for-all. Providers largely charge what they can get away with, often offering different prices to different insurers, and an even higher price to the uninsured.

Some specific examples:

In 2009, Americans spent $7,960 per person on health care. Our neighbors in Canada spent $4,808. The Germans spent $4,218. The French, $3,978. If we had the per-person costs of any of those countries, America’s deficits would vanish. Workers would have much more money in their pockets. Our economy would grow more quickly, as our exports would be more competitive.

There is a quote from Tom Sackville, who served in Margaret Thatcher’s administration. He explains that in America, healthcare is much more of a routine business (“very much something people make money out of” than anywhere else, where there may be embarrassment at making so much money from patients.

Something Klein neglects to mention but is picked up in the comments by a user named “blert” is how Americans subsidize the cost of medicine for everyone else by investing so much money in research and development:

[S]ome of the development of MRI technology happened in Britain. Most was performed in the U.S. Who is paying for the cost of development of this and other new technology and drugs? It’s often not the people in places like Canada and France, where government controls hold down prices. Most of the cost of research and development is paid for by Americans. We pay perhaps five times more in the U.S. for some procedures than people in France pay, but the technology might not exist in the first place if we didn’t pay this disproportionate share. Once the technology exists, companies keep charging as much as they can in the U.S. to recoup costs and to fund development of the next big thing in medicine, and meanwhile other countries in the world adopt the technology, gaining benefits from it without actually paying the costs. This is Canada, France, and much of Europe. Plenty of medical research goes on in these countries, but American consumers ultimately bear most of the cost. It’s an unfair system in many respects, but it’s what has kept medical research moving ahead for the last several decades.

Healthcare is such a complex topic that I realize that nothing I (or Klein) can write in the blog post can begin to fully explain the difference in healthcare costs in America vs. that of Europe. But hopefully the quotes I provided are food for thought.