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.

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(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.

How Alzheimer’s Disease Spreads

Researchers at Columbia and Harvard performed an experiment with genetically engineered mice that could make abnormal human tau proteins and have found a path for the spread of Alzheimer’s disease:

Alzheimer’s researchers have long known that dying, tau-filled cells first emerge in a small area of the brain where memories are made and stored. The disease then slowly moves outward to larger areas that involve remembering and reasoning.

But for more than a quarter-century, researchers have been unable to decide between two explanations. One is that the spread may mean that the disease is transmitted from neuron to neuron, perhaps along the paths that nerve cells use to communicate with one another. Or it could simply mean that some brain areas are more resilient than others and resist the disease longer.

The new studies provide an answer. And they indicate it may be possible to bring Alzheimer’s disease to an abrupt halt early on by preventing cell-to-cell transmission, perhaps with an antibody that blocks tau.

According to Wikipedia, there are more than 25 million sufferers of Alzheimer’s worldwide. This is a disease that is predicted to affect 1 in 85 people globally by 2050. It’s encouraging to see progress being made in this field, even if we are many years away from a cure.

Confessions of a Surgeon

Some money quotes from Paul A. Ruggieri’s upcoming book, Confessions of a Surgeon (subtitled: The Good, The Bad, and the Complicated)… First, you should realize that surgeons are people too, and so are prone to outbursts:

Surgeons are control freaks. We have to be. And when things don’t go our way in the operating room, we can have outbursts. Some of us curse, some throw instruments, others have tantrums. These explosions are a go-to reaction when we’re confronted with the ghosts of prior complications.

On blood loss during surgery:

The reality is that blood loss can be measured. Hospitals know which surgeons are losing blood, and how much, during every operation. They have data from their operating rooms, but the public cannot get access to this information. And this information matters, too. A large amount of blood lost during an operation can be a harbinger of complications to come.

Finally, this is strange and unexpected:

Surgeons frequently have conversations with the body parts or organs they are trying to remove. We also have conversations with ourselves; it’s a way to blow off steam while our minds scramble to deal with the unexpected.

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(via Wall Street Journal)

The Placebo Effect and the Self Management System

Nicholas Humphrey, a theoretical psychologist and author of A History of the Mind, has a fascinating post on the placebo effect and the relation between the health management system and what he dubs the self-management system. The basic premise is this: we know the placebo effect has a way of making people feel better in the medicinal sense. But what if we could prime people to change their behavior, attitudes, and personality?

It’s been a tremendous surprise for experimental psychology and social psychology, because until now it’s been widely assumed that people’s characters are in fact pretty much fixed. People don’t blow with the wind, they don’t become a different kind of person depending on local and apparently irrelevant cues . . . But after all, it seems they do.

So if we don’t discount the placebo effect in medicine, how does it fit in with the rest of the argument?

Placebos work because they suggest to people that the picture is rosier than it really is. Just like the artificial summer light cycle for the hamster, placebos give people fake information that it’s safe to cure them. Whereupon they do just that.

This suggests we should see the placebo effect as part of a much larger picture of homeostasis and bodily self-control. But now I’m ready to expand on this much further still. If this is the way humans and animals manage their physical health, there must surely be a similar story to be told about mental health. And if mental health, then—at least with humans—it should apply to personality and character as well. So I’ve come round to the idea that humans have in fact evolved a full-blown self management system, with the job of managing all their psychological resources put together, so as to optimise the persona they present to the world.

You may ask: why should the self need any such “economic managing”? Are there really aspects of the self that should be kept in reserve? Do psychological traits have costs as well as benefits? But I’d say it’s easy to see how it is so. Emotions such as anxiety, anger, joy will be counterproductive if they are not appropriately graded. Personality traits—assertiveness, neuroticism, and friendliness—have both down- and up-sides. Sexual attractiveness carries obvious risks. Pride comes before a fall. Even high intelligence can be a disadvantage (we can be “too clever by half”, as they say). What’s more—and this may be the area where economic management is most relevant of all— as people go through life they build up social psychological capital of various kinds that they need to husband carefully. Reputation is precious, love should not be wasted indiscriminately, secrets have to be guarded, favors must be returned.

So, I think humans must have come under strong selection pressure in the course of evolution to get these calculations right. Our ancestors needed to develop a system for managing the face they present to the world: how they came across to other people, when to flirt, when to hold back, when to be generous, when to be mean, when to fall in love, when to reject, when to reciprocate, when to punish, when to take the lead, when to retire, and so on. . . All these aspects had to be very carefully balanced if they were going to maximize their chances of success in the social world. 

Fortunately our ancestors already had a template for doing these calculations, namely the pre-existing health system. In fact I believe the self management system evolved on the back of the health system. But this new system goes much further than the older one: it’s job is to read the local signs and signs and forecast the psychological weather we are heading into, enabling us to prejudge what we can get away with, what’s politic, what’s expected of us. Not surprisingly, it’s turned out to be a very complex system. That’s why psychologists working on priming are discovering so many cues, which are relevant to it. For there are of course so many things that are relevant to managing our personal lives and coming across in the most effective and self-promoting ways we can.

You should read the entire piece here.