Bloomberg News Points Out The Need for a "Star Trek"-like Medical "Tricorder."

I.  Bloomberg News Highlights a Serious Healthcare Problem 

OK, that’s not quite what Bloomberg News reported on December 30--the word “Tricorder” does not appear in the story anywhere at all.  But we can say this much for sure: The piece highlights the need for better solutions, and a Tricorder would be a great solution.  

Instead, the Bloomberg report chronicled abusive and excessive surgery practices in Minnesota; the muckraking headline reads, “Doctors Getting Rich With Fusion Surgery Debunked by Studies.” Written by reporters Peter Waldman and David Armstrong, the 3500-word article focuses on alleged misdeeds in the Gopher State, even as the article extrapolates that state’s problems on to the rest of the country.   Yet as we shall see, these kinds of abuses--and other problems of medicine--won’t genuinely get better until more technology is provided; provided to the doctor, to the patient, and to all of us.  

The Bloomberg article begins with the story of a Minnesota man, Mikel Hehn, who in 2008 received a spinal vertebrae-fusing operation that turned out badly for him; he is now in chronic pain, taking 10 different medications to deal with chronic pain and depression.  The issues raised here are, indeed, complicated.  We might note, for example, that Hehn had been told by a doctor in his hometown of St. Cloud that he didn’t need the spinal fusing procedure, and so Hehn went to Minneapolis to get a second opinion--and got the operation, with disastrous results.  Other Minnesota patients, too, suffered bad results from their vertebrae surgery--one even died.   

The piece cites further horror stories concerning back surgery in Minnesota, and goes on to suggest close collaboration between doctors and medical equipment companies, suggesting that doctors and companies are working together to perform more back surgeries, hiking up profits for both.  Finally, the piece indicates that Minnesota is a one-state microcosm for the country, citing a government estimate that unnecessary surgery of all kinds costs the nation $150 billion a year.   The Bloomberg reporters further note:

The number of fusions at U.S. hospitals doubled to 413,000 between 2002 and 2008, generating $34 billion in bills, data from the federal Healthcare Cost and Utilization Project show. The number of the surgeries will rise to 453,300 this year, according to Millennium Research Group of Toronto. 

The possibility that many of these and other surgeries are needless has gotten little attention in the debate over U.S. health care costs, which rose 6 percent last year to $2.47 trillion. Unnecessary surgeries cost at least $150 billion a year, according to John Birkmeyer, director of the Center for Healthcare Outcomes & Policy at the University of Michigan.

“It’s amazing how much evidence there is that fusions don’t work, yet surgeons do them anyway,” said Sohail Mirza, a spine surgeon who chairs the Department of Orthopaedics at Dartmouth Medical School in Hanover, New Hampshire. “The only one who isn’t benefitting from the equation is the patient.”

So what could we do to better warn patients against the overuse of this fusion procedure?  What can we do to inhibit doctors from over-medicating?  And how can all the rest of us be alerted to such overuse?   

II.  Non-Solution Solutions 

First we might review what is not likely to work.  What won’t work, unfortunately, is what’s likely to happen next.  

We might begin by recalling that politicians, confronted with bad news, feel the immediate impulse to “do something.”  It will be easy, for example, for a lawmaker to hold a press conference, or to hold a victim-heavy hearing in front of TV cameras, and to then offer legislation to “fix” the problem.  In other words, politicians have a template through which they see a crisis: Decry the problem, further highlight the problem, and then legislate against the problem.   

But as we have learned over the years, many legislative fixes--especially those fueled by a sudden wave of outrage--end up making the problem worse.   If the “solution” to the problems identified in Minnesota is simply to put a layer of regulatory bureaucracy atop the current system, regulating the behavior of all the medical and financial players, well, that’s not overly promising.  
  

We can further observe that the Obama administration will undoubtedly take note of this story, and use the facts cited herein to further its own healthcare policy agenda.   The Healthcare Cost and Utilization Project, for example, which produced the $150 billion estimate for unnecessary operations cited in the article, is a unit of the federal Agency for Healthcare Research and Quality.  And AHRQ, in turn, is a part of the US Department of Health and Human Services; HHS Secretary Kathleen Sebelius is the point person for the Obama administration’s efforts to slow down the rise in healthcare costs--by any means necessary, in the opinion of some.  So those who mistrust the Obama administration’s healthcare efforts--officials have said, many times, that the goal of reducing healthcare costs is more important than improving healthcare results--might feel concerned that the Obamans will seize upon this article to restate their argument that federal experts must step in to cut costs.  In other words, officials of the executive branch will step in, alongside Members of Congress and other elected officials, to “do something” about over-medication.  

The immediate abuses, such as they might be, can be curbed, but as we have learned, over the long run, those being regulated have a way of evading, even subverting, the regulation.  Moreover, if the new rules are applied heavy-handedly, they can make the situation worse. 
  

The beneficiaries of current spinal surgery practices--including the surgeons, the hospitals, the medical equipment companies--know exactly who they are, and what they stand to benefit from a continuation of the system.  Confronted with a threat to their revenue, they will bulk up on lobbyists and lawyers and p.r. people, muster their own counter-arguments.   

Down the road, assuming that some legislative or regulatory change is enacted, we all might discover that the government is not always efficient or competent at what it does.  

Moreover, individual bureaucrats, as well as whole bureaucracies, are subject to “capture”--that is, they become captured by the industries they are supposed to regulate.  In analogous situations across US history--the regulation of the railroads being a paradigmatic instance--the result of greater regulation might have been a short-term increase in “fairness,” but the longterm result was not only a stifling of innovation in an industry but also the overall decay of that industry.   In the case of past regulation, for example, the regulators and the regulatees settled into their new relationship, which soon came to be defined as the mutual maintenance of the status quo. We can add that one status-quo-maintaining result that generally pleases both sides of any regulatory equation is the raising of barriers to entry for would-be newcomers into the field.   That is, if ever player in a given industry is to be regulated, then, of course, each player must be suitably licensed, certified and inspected.  And each of those actions generally makes it harder for new entrants to get into that economic space.   As barriers to entry rise, there’s an inevitable slide in quality--which can soon become a collapse of the industry.   It’s happened before, it can happen again.   In the world of bureaucratic politics, not much has changed since the 19th century--it’s the nature of bureaucracy that’s a constant.   

One variable is that is new, however, is large-scale tort litigation.   The Bloomberg piece is undoubtedly going to attract significant attention from trial lawyers, always sniffing around for new cases.  Nobody should be surprised to see a flurry of lawsuits pouring forth, as trial lawyers look forward to stoking jury passions, already inflamed by the hot news of the moment, in pursuit of big judgements.   Using their legal power of “discovery,” tort lawyers might even discovery new kinds of individual or corporate culpability--that’s what happens when thousands and millions of documents are culled over.    And yet nothing, we should note, in the litigation arsenal actually makes healthcare and medicine better. 

So while some abuses identified in the Bloomberg article might be investigated or regulated out of existence, the overall condition of the industry--and of healthcare--could well get worse.  That’s a negative outcome that merits the attention of all of us. 

Under current parameters, the problem of over-medication is essentially insoluble, we might say, because it results from at least three sources.  First, some doctors be willing violate their professional oath by over-medicating; second, because of corporate cupidity--the zeal to sell things to people that they don’t need.  And third, many patients--influenced, perhaps, by the culture--to demand that something done about their medical problems, even if that “something” makes their own problem worse.   The only “solution” would be a drastic clampdown on medical care, a hammer coming down on the medical-industrial complex.  And if that hammer were to come, it’s a safe bet that overall healthcare would get worse, not better.   

So what can be done?  How do we break out of this regulation-litigation back-and-forth along the  flat-to-negative axises of bureaucracy and litigation?   How do we push things on an upward path?  How do we enact genuine reforms so that patients get the best possible medical advice, as well as the best possible medical devices?   

Here we might be reminded of the wisdom of Albert Einstein, who said, eloquently and elegantly, “No problem can be solved on its own level.”   

III.  The Medical Grid

The Tricorder, not mentioned, in the Bloomberg piece, will have to wait.  But it shouldn’t wait long, because as we have seen, many of the problems pinpointed by the Bloomberg article are insoluble in the current environment.   More regulators and litigators is not a formula for better healthcare.  

Instead, we we will need a deus ex machina--in the most literal sense, we will need a machine coming down from the sky to solve the problems that the Bloomberg article highlighted, and many other problems, as well.   Fortunately, that’s possible, if we wanted to work toward bringing it into existence.
   

For all the problems of healthcare, we might note one in particular: At the heart of the current system is an inefficient and information-deprived relationship--the relationship between the patient and his or her doctor.   Doctors save lives, to be sure, but they have vastly more power than patients, and as we have seen, that power can be abused.   

As the Nobel Economics Laureate Kenneth Arrow demonstrated a half-century ago, an endemic problem in medicine is “asymmetric information.”   That is, the doctor knows a lot more than the patient, and, indeed, the medical system itself knows a lot more than the patient.   So if the doctor, or the system, says that the patient needs something, the patient can’t be expected to know enough to negotiate the optimum outcome with the doctor.  Yes, getting second opinions can be valuable, but some of the most expensive medical situations arise when the patient is in distress, and thus can hardly be expected to think with clarity or patience.  If the patient ends up in an emergency room, there’s not much dickering over price to be done.    We might note that in an asymmetric environment, the problem can go both ways--toward over-medicating, and also under-medicating.   Either way, if the experts say one thing, it will be hard for an ordinary citizen to argue the other way.    

This Arrow asymmetry information inevitably inspires some to look for outside forces to help monitor the practice of medicine.  Health insurance entities, public and private, seek to apply metrics to care, using data to identify, for example, “hot zones” of over-treatment.  (They rarely seem to worry, these days, about under-treatment.)     

Yet another way of looking at the asymmetric relationship is to describe it as a “boutique.”  By “boutique,” we mean that each medical case is handled in relative isolation from other cases, and  as a result, each case risks being isolated from fast-changing awareness as to best practices.  Doctors, whether they work by themselves or as part of a group practice, are hard-pressed to keep up with the literature in their field, even if they are fully and single-mindedly motivated.   There’s simply too much information.   

In other fields, the information glut is automated to the point of being manageable, at least for the task at hand.  Systems are turned into algorithms, boiling down the decision-making process to a relatively few key decision points.   And so complex tasks become simpler, and simple tasks become easy.   Cashiers, for example, no longer have to do math, or even look at the price of items--the prices are scanned in, along with sales tax, discounts, and “rewards” system; meanwhile, the system itself is notified as to what goods are  selling, and what inventory needs to be restocked.    These days, we say that the system itself resides in a “cloud,” defined as all the hardware and software that makes up the decision-making process.   The whole system is automated to speed up the consumer experience and to minimize error and expense.   Of course, if the process looks simple on the surface, the reality is that millions of people have put in billions of hours to figure out how to do all this--it takes a lot of work to make things simple.  But of course, there will always be people, too, in the mix,  There are plenty of robot factories around the world, but we keep humans around in each and every one of them, just to keep track of the ‘bots.   

So is medicine the same as merchandising?  Can we reduce patients to the same level as cans of soup?   Of course not.   But going back to the days of Norbert Wiener, cyberneticists have understood the deep unity of information--in the end, it’s all ones and zeros.   Any problem that can be reduced to ones and zeros can, in turn be solved by the “data crunching” of those same ones and zeros.  That’s the science.  The art, of course, is providing the right intellectual and ethical framework for the information, as it is brought up the scale of complexity, from raw material to finished product.  That is, as those ones and zeros are built up into databases and networks, where their value can be safely and pleasingly used for the benefit of humans.  We can do all this, we can put more information “on the grid,” if we want to, while protecting personal privacy and dignity.   This “gridding” effort might seem complicated, but it is not impossible.  And there are huge gains to be made, as we shall see.   

By now, we have put most important things on “the grid.”  And by “grid” we mean not only the Internet, not only the cloud, but also all larger systems of predictability and transparency, such as the law and codified best practices (which, of course, can be online, in the cloud, among other places).    

The basic notion of time, for example, is on the grid.   That is not, not only does Greenwich Mean Time exist as an objective measure of “best practice” on time, but we all have free and easy access to GMT.   In addition, we all have watches, clocks, and other time pieces, including the now ubiquitous cell phone.   So if we were ever to make an appointment to see an “expert” on time, we would always have a “second opinion” at our fingertips.   The timing device would be our own expert, our own check-and-balance against whatever the “expert” might say.   At one time or another--before the institution of regularized time-zones, for example--time was a huge issue, and mistakes and even tragedies resulted from mistakes.  But now, after centuries of working at fully transparent and abundantly available time, the quality of timekeeping in this country is not much of an issue, and certainly not a crisis.    

Other crises, too, have been alleviated.   Auto repair, for example, has long been a problem area, for reasons of information asymmetry.  Auto mechanics were able to take advantage of customer ignorance; what’s changed, to some extent, are not only the laws and regulations, but also the information environment in which auto repair exists--more information is on the grid.   Parts are modular, there’s more transparency on prices, and there’s a huge industry of do-it-yourself home repair--many lessons are available online.   On YouTube, for example, “auto repair how to” yields up 5540 “hits,” and there are thousands more videos to be found.   For the consumer, the more information, the better.   

As the late Daniel Patrick Moynihan said, we are all entitled to our own opinion, but we are not entitled to our own facts.   The creation and distribution of quality information is vital work, comparable to creating a dictionary in the past, or standardizing weights and measures.   

So we can say, then, that the real issue is expunging bad information practice.  To the extent that we are able, we need to equalize information among all players.   With a few exceptions bad information practice is not a question of good and evil, it is a matter of inefficiency and incompetence--how quickly can information diffuse?
    

To be sure, all of this is complicated.  But humanity has demonstrated that it can handle more complexity.  More to the point, with great effort, we have built the machines that will enable us to manga all this complexity.   Anyone’s laptop computer today has more processing power than existed in all the world sixty years ago.   And the fastest supercomputer today has achieved a processing rate of more than 2.5 “petaflops” per second; that is, 2.5 quadrillion (a thousand trillions) per second.

And computers can do things that once seemed nuanced and subtle.  The game of chess is both and art and a science, and it is certainly complicated; there are 400 different positions in a chess game after each player makes a single move, and 72,084 positions after each player has made two, and nine million or more positions after three moves.  The estimated number of legal positions in chess is estimated at between 10^43 to 10^123; that’s a 1 with 43 zeros after it, unless it’s a 1 with 123 zeros after it.  Indeed, some observers insist that the true number of possible chess positions is infinite.  And yet since 1997, computers have been beating humans at their own game.  

Of course, medicine brings with it ethical issues that transcend any mere game.  But some of the issues in medicine are simply complicated puzzles that need to be solved--and that’s where computers excel.  Consider some bone issues: How did we figure out that Vitamin D cures rickets?   Or that calcium supplements help with osteoporosis?  Or that glucosamine alleviates arthritis?   Those over-the-counter approaches might seem simple, but they are only simple in retrospect.  They weren’t simple at all on the front end.    Aspirin is dirt cheap now, but it was the wonder-drug of its time, and, come to think of it, it still is a wonder drug, even if it is abundant.

That’s the problem-to-solution scenario that we want to see repeated, over and over.   Before computers, humans were able to solve many of these problems, with computers, they can solve many more.  

And so what about back pain?   Back pain, after all, was the issue that got us started--what to do about costly and ineffective treatments in Minnesota?   Can computers crunch our way to a solution for back pain?  

And the answer is, we don’t know yet.   But what we do know is that computers, combined with databases, can put information about backs on the grid, for the benefit of doctors, patients, and the public interest.   

Using the medical grid, we can make better medical information averrable to all concerned.  And in making it available, we can make it symmetrical.   When information is available and symmetrical, it becomes predictable--predictable in the good sense, in the way a ruler is predictable in being exactly 12 inches long, or that a good is guaranteed to contain exactly what the label says it contains.   When all the dimensions of a problem is known and understood, the solution gets easy.    

Doctors might be offended by these comparisons, but then, we might note, all boutiquers are offended by the idea that what they do can or should be mass produced.  By their nature, boutiquers like the idea that they can and should craft out a specific solution to each specific problem.   Yet the downside of boutiqing is that the result can be expensive, and also that it can also suffer from randomness and variability in the doctoring, as well as corruption.  The solution, therefore, is standardization.  Yet as we have seen, we are not talking about mass production.  We are talking, instead, about personalization of a kind that can only occur atop a platform of predictability and quality.  The doctor should always feel free to make an innovative recommendation to the patient, based on his or her own judgment, bolstered by the cumulation of all medical learning--and only a computer can make that possible.   The upside of “boutiquing” is that a solution can be crafted out for each specific situation, but the downside--making a horrendous medical error--is covered by the computer.   

But by the same token, the patient, too, should have access to the best available information, too. Indeed, there’s no reason why the patient shouldn’t see the same information that the doctor has.  Yes, the information is inherently complicated, but that’s where the arts of presentation come in, to help the patient see and understand what his or options might be.  Such art, along with the science of ergonomics of science, moves us toward the complicated becoming simple?  If it can be done for cashiers in stores, it can be done for patients in medical offices.    If knowledge is power, as Francis Bacon said, we all need more knowledge. 

Meanwhile, the reality is that we are already moving in this direction, toward computerization,  albeit at an agonizingly glacial pace.   Much medical information is already on the grid--just not enough.   

How do we get more medicine on the grid--and faster?   We are all familiar with information services such as WebMD,  The Health Central Network,  and Patients Like Me, but those services, valuable as they are, can only rarely get inside the “decision loop” of doctors and patients.  That is, the outside services rarely have access to the needed information about the individual patient.  And from the companies’ point of view, that’s a good thing.  Why?  Because under the current regulatory regime, as legal expert James R. Wootton points out, they would risk being sued for any mistakes that get made in their name.  As we have learned by now malpractice consists of the judgment of a jury, as distinct from what is objectively and demonstrably true.   

Similarly, we have seen that electronic health records (EHR) have not yet taken off.   It seems hard to believe that in an era when credit card companies, for example, process trillions of calculations about sales, that we have not achieved a similar record-keeping of medical information.   But as legal expert Wootton explains, the same fear of liability keeps records from being automated--if all data were automated, it could just as easily be searched by a trial lawyer as by another doctor, and no doctor can afford unlimited predatory searching.  If we want the benefits of large databases, we have to seal them off from John Edwards & Co.   Absent such a change, it’s likely that the Obama administration’s multi-billion dollar effort to digitalize medical records will prove to be a deep disappointment.  

And so, of course, if we can’t even digitalize--digitalize in a larger, data-base sense--EHR’s, which are retrospective, there’s little reason to be optimistic about digitalizing such records as a prospective tool for medical treatment.     

Thus the opportunity to improve healthcare is being lost.   If Mikel Hehn, the man in Minnesota with the bad back, had been able to read an instant summary of the case history of all who had his condition, his surgery, then he might have made a different decision.  And if the doctors who did the procedure had access to the same counter-indicating information, they might have been more hesitant to prescribe surgery that was so hard to defend in the court of medical opinion,  And finally, with better information, fully transparent to all of us, we would all be able to see trouble spots.  That’s what the Dartmouth Atlas purports to do, although its methodology has come under severe challenge.  Such disputation is not a final argument against Dartmouth or the Dartmouth approach, it’s simply a reminder that for others portals, with their own ideas, should enter the same space.  As we all know, an individual data point can be true, but it can be framed into a context that is misleading at best and flatly inaccurate at best.  As the late Jack Kemp said of all experts, “They don’t care that you know till they know that you care.” 

And that’s the problem with Obama approach--people don’t dispute that they have knowledge, but they do worry that they have empathy, and the right medical model in their heads.   And so, for example, the best way to deal with the problem of back pain is to cure back pain.  And if we aren’t there yet, we should get there.  And getting there, getting to a cure, will require more technology, and more trial and error, not less.    

But even along the way, we will see incremental gains.   

If, for example, if a 40-year-old man with back pain goes to the doctor, it would be very helpful to her if both he and her doctor had full access to the full medical information about every other man of her age group who shared her characteristics.   Out of that welter of data, the best medical conclusion would come.   We know that the more data, probably structured, the better.  That’s why the Internet is so valuable, and why search engines and databases that properly structure needed information are even more valuable. And that’s what we all need: A machine that helps us to manage all the information about one of the most precious things we have: our health.  To get there, of course, the “med mal” liability issues would have to be dramatically revised. 

  

But where would this information come from?  And what about privacy?   Would we all want to contribute data to the large cloud?  Who would do all the work?  

The recent experience of the Net is that many people are happy to put up information, and to do real work--all to help others, for no direct gain to themselves.   Wikipedia is the most obvious example, but so are millions of other sites on which people labor at length to create value for others, for no monetary reward.   Many of those sites, of course, concern medical issues--protests against bad treatment, advice on good treatment, and general commentary on health matters.  To be sure, there’s no system-wide quality control, and that’s a problem.  So there’s real value to be found in building up a “brand name,” or names to monitor this information, all the while making it easy to understand by the widest possible audience.   

And as for privacy, those concerns, too, must be addressed.   Uploaded information can be be “de-identified” before it goes into the database; that’s the way that the Federal Aviation Agency handles the sensitive air-safety information that it collects from each airline.   

So how do we get doctors to participate?   As of now, it is estimated that doctors only record about 1 percent of the information they get about a patient.  Part of the reason, of course, is time--it takes time to write things down.   And yet as we know, many of us already possess devices that we use to collect and record data: Examples include heart-rate and blood-sugar monitors, as well as all manner of devices we use to measure are calorie consumption and exercise.  In addition, many machines, from hearing aids to heart pumps, generate information that could be recorded in a doctor’s office, among other places, including the home (which would probably be the best place, although in the “clouded” era, location doesn’t mean as much as it once did).   And one day soon, RFID chips in individual pills will generate still more valuable  information.   

Indeed, it’s already possible to see an “internet of things,” that is, devices communicating with each other, in a language that other devices are equipped to receive and transcribe.  As we have seen, it’s those sorts of rote tasks that machines are so good at doing; the dullest and most routine tasks can be automated, if we are willing to automate them.   But to automate the collection of vast troves of information, and then to centralize them, is to make an open invitation to lawsuits; so once again, we can pause to note that no kind of EHR is going to work if it opens its way to more lawsuits.  So those laws will have to be changed.    That’s not a small undertaking, but it is a necessary undertaking. 
  

That’s the goal: The gridding of medicine in a way that improves personal health, not tort-lawyer wealth.   But now let’s go further, boldly going where no man--and no woman--has gone before.

IV. Beaming Up The Tricorder  

The Bloomberg article makes plain that we have a serious problem.  And yet as we have also seen, traditional politics is unlikely to come up with a useful answer to those problems.  The best answer is not going to be bureaucrats snooping around, getting in between patients and doctors, nor is it going to be trial lawyers swooping in to profiteer.  Indeed, any proposed “solution” that involves having the government more closely monitor the doctor-patient relationship is likely to be harmful, and to generate a backlash. If people are at least somewhat resentful of the information asymmetry possessed by doctors, they are very resentful of the power asymmetry possessed by government officials.  Moreover, any proposed “solution” that seems to impinge on patient privacy is also a non-starter with ordinary people, while any move toward EHR’s that opens the way to more lawsuits is a non-starter for professionals.     

So how to do all that?  In Einsteinian terms, we need to take the problem up a notch, to a new level of technology; we will only solve this problem on a higher level that takes us from the age of bureaucracy to the age of cyber-technology.   And so we need a Tricorder.  

We all remember the Tricorder from “Star Trek.”  It was the handheld device that Starship Enterprise’s Dr. McCoy used to diagnose patients, among other critical functions.   OK, the Tricorder is a fictional device from a TV series set in the 23rd century, but as we have been reminded over and over again, many times real-world solutions come from sci-fi imaginations.   People imagined human flight, for example, and rocket ships, and space travel, long before scientists knew how to achieve those goals. And yet as the website Technovelgy endlessly reminds us, the dreams of literary fabulists have often encouraged practical scientists and engineers to render those imagined things into reality.   

So the challenge is to maintain the boutique benefits of individualized treatment, while also gaining the “scalable” benefits of standardization and mass production.   There is a way, first seen in the 1960s in fanciful form, but now possible--albeit, as a practical matter, a very long way off.   

So if we can enter the “Star Trek” universe, we can say that the Tricorder is a 23rd century portable computer.  And because it is a computer, it must rely on pattern recognition; whatever the symptoms of a disease or an injury might be, even if they are not visible to the naked eye, the Tricorder see them and make sense of them--it recognizes them   That’s pattern recognition, an it’s based on a computer’s ability to crunch through, quickly, a huge number of variables, until it settles on the best candidate for an answer.  And so one way another, each Tricorder computer must be hooked up to “the cloud,” as we call it in the 21st century.   That is, each unit is tethered to vast databases that enable it to identify a disease or syndrome, even if it occurred somewhere else in the galaxy.  That’s what makes the Tricorder so effective: It is on the grid, a universal grid.  It knows everything, and so, of course, it could diagnose everything.

To be sure, the Tricorder can do things that we don’t know how to do.  For example, Dr. McCoy can simply point the Tricorder at a patient and make all manner of diagnosis, instantaneously.  We aren’t there--yet.  But we are getting closer.  Lasers and ultrasound at least point us in the direction of instant diagnosis. So that’s a challenge ahead--to make it ever more real.  

On the other hand, if we look at the picture above, from the mid-1960s, we can see that the Tricorder looks distinctly low-tech.   Indeed,, an Apple iPhone or other smart device is a lot cooler and sleeker than the Tricorder; so in that sense, the machines of 2010 have already leapt ahead of the envisioned machines of the 2200s.    

So we might ask: If smartphones can do so many things, why aren’t they being used more to better our health?   Why is medicine being bypassed in this technological revolution coming out of Silicon Valley?   Why aren’t we moving toward Tricorder-ization?  The answer, as have seen, is that the obstacles to Tricorderization are more legal than technical.   If a smartphone has  access to vast databases to play a game or to buy something, yes, mistakes can happen, but liability is sharply limited--and so such access is a done deal.  But if access to medical records means liability for medical mistake, fuhgeddaboutit.   

The challenge, then, is to make function as niftily effective as form.   And that will require a new kind of framework--a framework of legal and regulatory protection.   Legal protection, we might add, not for the sake of coddling malefactors, but for helping push technological development forward.   

Otherwise, smart as our smart phones might be, they won’t ever do what a Tricorder could do.  Machines can keep track of things for us, but the smartest smart phone can’t diagnose.  We want a smartphone that can go toe to toe, as it were, with a doctor about diagnosis and treatment.  Even if we don’t yet have the technology to make distance-diagnosis of ourselves, we do have the technology to download all pertinent data from the cloud, and from that download we could create a proxy, or avatar diagnosis, based on all available information from throughout the network.  And that proxy diagnosis could be used to benchmark the doctor’s diagnosis.   And that could have been useful in providing an instant second opinion about whether, for example, a doctor in Minnesota is too eager to prescribe a vertebrae-fusing operation.  

If we will need a Tricorder in the 23rd century, we need it, too, in the 21st century.  And we could be making the early versions, now, if we possessed the political vision.

And if we could, we would be addressing the problems identified in that Bloomberg article in a constructive way.   We would be using information as a Baconian power tool--to empower all of us to make better choices, to live better and longer lives.   

"Death Panels" Redux

The New York Times' Robert Pear outlines the Obama administration's plan for reviving "end of life counseling," which Sarah Palin labeled "death panels."  Barack Obama & Co. denied that they were any such thing, of course, but the provisions of Section 1233 were left out of the Obamacare legislation, signed into law earlier this year.

But now, during a slow news time, they have returned as regulations issued by Medicare authorities, supported by many Democrats in Congress, such as Rep. Earl Blumenauer of Oregon.  Yet the proof that Democrats think that they have something to be defensive about is found in this passage from the Times article: 

Mr. Blumenauer, the author of the original end-of-life proposal, praised the rule as “a step in the right direction.”

“It will give people more control over the care they receive,” Mr. Blumenauer said in an interview. “It means that doctors and patients can have these conversations in the normal course of business, as part of our health care routine, not as something put off until we are forced to do it.”

After learning of the administration’s decision, Mr. Blumenauer’s office celebrated “a quiet victory,” but urged supporters not to crow about it.

“While we are very happy with the result, we won’t be shouting it from the rooftops because we aren’t out of the woods yet,” Mr. Blumenauer’s office said in an e-mail in early November to people working with him on the issue. “This regulation could be modified or reversed, especially if Republican leaders try to use this small provision to perpetuate the ‘death panel’ myth.”

Yes, that's exactly what could happen.  

As an aside, we can note the url that the Times used for this story.  Note that the "slug," as it would have been called in the old days, is "death": 

Evidently the Times does believe in calling it like it is--at least some of the time.  

How to stop organ smuggling: The ultimate answer is technological abundance, not scarcity and criminality.

The Guardian today reports on credible accusations that the prime minister of Kosovo has run Kosovo as a mafia state, trafficking in human organs, as well as drugs and guns.    In the meantime, though, we might be thinking about a better way to provide organs to people.   And we might note that what people want, desperately, is organs and other ways to improve and extend physical life.  Nobody tries to smuggle health insurance.  

The Guardian report opens up myriad questions, but from a Serious Medicine point of view, we might dwell on the phenomenon of organ trafficking, which seems to have been centered on kidneys; as the Guardian puts it, “a number of Serbs are said to have been murdered for their kidneys, which were sold on the black market.”  These alleged crimes are horrendous, and the perpetrators should be pursued with the full force of the law.  

However, we might note that black markets arise as the result of two related phenomena: illegality and shortages.   If something is illegal but also in demand, it will likely be in short supply, and that in turn will create a black market.   And so it is with human organs, including kidneys.   Thus even if the Kosovar black market is shut down, it’s a safe bet that it will continue elsewhere in the world.   

It’s easy to see why dangerous drugs are in short supply, because they should, of course, be illegal--because they are toxic.   They are intrinsically bad.   And so the black market in dangerous drugs, too, should be snuffed out.   

Yet organs are in a different category: Their provenance--say, from someone murdered for the sake of the organ--may make them contraband, but the organ itself is not intrinsically bad.  This is not an argument for some sort of benign treatment of the illegal organ trade.  Instead, we should be looking for ways to expand the supply of kidneys and other organs, so that the black market disappears.  After all, we want the organs, we just don’t want the criminals.  

Legal organ donor programs are one meritorious approach to expanding the supply, but the organ-donation process is still hit or miss, because there aren’t enough organs being donated.  Moreover, on short notice--as in the case of a donor who dies suddenly--it’s difficult and expensive to match the right organ with the right recipient.  The result is an illiquid organ “market” characterized by long wait times--and that means, of course, that the legal supplying of organs can still take on black-market features, starting with queue-jumping.    

So what’s the answer?  The answer is to increase supply.  Some have suggested creating a “white market” for organs, but such a system--which inevitably would become some sort of auction-- will always be disturbing to some, and will inevitably blend back into a black market, as in the case of the incompetent or the unwitting being “persuaded” to become organ sellers.   

The real answer is to cut the connection between the organ leaving one body and entering into another body.  That is, create new organs in the lab, and then the factory.   There’s plenty of work going on in this field, through cloning and 3-d printing, but we’re not there yet.   We don’t yet have a Henry Ford of organ manufacture, providing organs in a legal and ethical manner--even using workers being good wages in good working conditions.  

Until we do get there--until we embrace a Serious Medicine Strategy aimed at abundance, not scarcity--we will always see stories such as the one in the Guardian, excerpted here:  

Kosovo's prime minister is the head of a "mafia-like" Albanian group responsible for smuggling weapons, drugs and human organs through eastern Europe, according to a Council of Europe inquiry report on organised crime.

Hashim Thaçi is identified as the boss of a network that began operating criminal rackets in the runup to the 1999 Kosovo war, and has held powerful sway over the country's government since.

The report of the two-year inquiry, which cites FBI and other intelligence sources, has been obtained by the Guardian. It names Thaçi as having over the last decade exerted "violent control" over the heroin trade. Figures from Thaçi's inner circle are also accused of taking captives across the border into Albania after the war, where a number of Serbs are said to have been murdered for their kidneys, which were sold on the black market.

Legal proceedings began in a Pristina district court today into a case of alleged organ trafficking discovered by police in 2008. That case – in which organs are said to have been taken from impoverished victims at a clinic known as Medicus – is said by the report to be linked to Kosovo Liberation Army (KLA) organ harvesting in 2000. It comes at a crucial period for Kosovo, which on Sunday held its first elections since declaring independence from Serbia in 2008. Thaçi claimed victory in the election and has been seeking to form a coalition with opposition parties.

Once again, the imperative of law enforcement aside, the ultimate answer to the organ shortage is is technological abundance, not scarcity and criminality.  

'The Alzheimer's Strategy We Need," for the Manhattan Institute's Medical Progress Today

Full text here.

James Watson’s Quest: “A Geneticist's Cancer Crusade: The discoverer of the double-helix says the disease can be cured in his lifetime. He's 82.”

A terrific and hopeful piece in The Wall Street Journal today: An interview with James Watson, the legendary co-discoverer of DNA, sharing the 1962 Nobel Prize for medicine with Francis Crick and Maurice Wilkins.    

The headline atop Allysia Finley’s story speaks to a positive can-do spirit rarely seen in healthcare journalism these days: “A Geneticist's Cancer Crusade: The discoverer of the double-helix says the disease can be cured in his lifetime. He's 82.”   In fact, Watson has been making this point for a while now; last year, in the midst of the Obamacare debate, he wrote a New York Times op-ed calling for victory in the war on cancer.  Yes, Watson was willing to use the “w” word: war.  Serious Medicine is a war against disease, while health insurance can be seen as a kind of accommodation--some might even say appeasement.   Yes, its true: cures are more important than care, even if the power class of Washington DC thinks the opposite--or at least acts that way.  

Here are some good parts of the new Journal piece:  

'We should cure cancer," James Watson declares in a huff, and "we should have the courage to say that we can really do it." He adds a warning: "If we say we can't do it, we will create an atmosphere where we just let the FDA keep testing going so pitifully."

The man who discovered the double helix and gave birth to the field of modern genetics is now 82 years old. But he's not close to done with his life's work. He wants to win "the war on cancer," and thinks it can be won a whole lot faster than most cancer researchers or bureaucrats believe is possible.

What’s missing in the political-medical discussion, Watson declares is one word: leadership:  

He says he's the better for it because it taught him how to be a leader, something he thinks there are too few of nowadays. "The United States is suffering from a massive lack of leadership. There are some very exceptional, good leaders. I'm not saying they don't exist, but to be a good leader you generally have to ruffle feathers," which Dr. Watson believes most people aren't willing to do.

Finley notes that Watson has some new enemies: 

"The FDA has so many regulations," Dr. Watson says. "They don't want you to try a new thing if there's an old thing that might work. . . . So you take the old thing, but we know cancer changes over time and we would really like to get it whacked early, and not late. But the regulations are saying you can't do these things until we give you a lot of s— drugs," he snorts. "Shouldn't this be the patient's choice to say I would rather beat the odds with a total cure rather than just to know that I am going to have all my hair fall out and then after a year I'm dead? . . . Why should [FDA commissioner] Margaret Hamburg hold things up? There's the cynical answer it gives employment to lawyers.” 

Ah, the lawyers. "Right now America is being destroyed by its lawyers! Most of the people in Congress just want work for lawyers." He quickly adds: "I was born an Irish Democrat, so I wasn't born into a family which instinctively says these things. But my desire is to cure cancer. That's my only desire."

And then some final words:

"I'm going to look optimistically and of course sometimes it doesn't work," he says. But "you move forward through knowledge. You prevail through knowledge. I love the word prevail. Prevail!"

Yes, prevail.  Win the war on cancer.   

South Korea goes to war against Alzheimer's Disease, and the rest of the world should join them.

“In a Land of the Aging, Children Counter Alzheimer's”--that’s the headline, datelined Seongnam, South Korea, in The New York Times this morning.   In that story, we see seeds of hope on Alzheimer’s Disease (AD)--not only for South Korea, but for the rest of the world.  Indeed, here in the US, the challenge is to get our policymakers to consider lessons, and to seize opportunities, from overseas as part of our own medical--and fiscal--strategy.

Times Reporter Pam Belluck, alongside another Times reporter, Gina Kolata, has performed a great service, opening our eyes to the worldwide dimensions of AD.  In  traveling around the world, covering what is, in fact, an international epidemic, she reminds Americans that we are not alone in this problem--and that we have many potential allies, if we can figure out how to ally with them.

In South Korea, a full nine percent of the population suffers from AD, compared to less than two percent of the population of the US.  And because advanced cases of AD require round-the-clock care, the disease is horrendously expensive to treat.  In the US, we already spend about $170 billion on AD, more than one percent of our GDP on AD; in South Korea, where the diseases is more than four times as prevalent, the burden is even greater.   And of course, there’s the even greater financial cost of lost productivity--not only for the afflicted, but also among caregivers--as well as the enormous humanitarian toll.

For their part, the South Koreans are taking positive measures.  According to the Times, South Koreans freely describe their anti-AD effort as a “war.”  And with a war comes society-wide mobilization.  (Yes, as we know, the South Koreans are also, of necessity on a war footing against North Korea; the fact that South Korea is under so much pressure, from so many directions, is an argument for the full utilization of productive resources, including helping people stay productive for as long as possible, so that their skills and talents can be utilized for the defense of the nation, as well as for medical cures.)

Indeed, the South Koreans are taking positive measures against AD.   They are organizing students to be part of caregiving, and consciousness-raising.  Belluck describes some of the lessons being drilled into a young student:

“Dementia is very bad for you, so protect your brain,” he said, with exercise, “not drinking too much sugar,” and saying, “ ‘Daddy, don’t drink so much because it’s not good for dementia.’ ”


At a Dementia March outside the World Cup Soccer Stadium, children carried signs promoting Dr. Yang’s Mapo district center: “Make the Brain Smile!” and “How is Your Memory? Free diagnosis center in Mapo.”

One might say that such efforts, in and of themselves, have limited value.  After all, right now AD is incurable; indeed, there is no real evidence that any sort of screening or palliative therapy does much good.   Yet still, it’s important to start somewhere; building a consciousness about AD  is a way of signaling to other aspects of society that AD is a problem, and that will hopefully trigger a problem-solving response.   In the words of one anti-AD activist:


“I feel as if a tsunami’s coming,” said Lee Sung-hee, the South Korean Alzheimer’s Association president, who trains nursing home staff members, but also thousands who regularly interact with the elderly: bus drivers, tellers, hairstylists, postal workers. “Sometimes I think I want to run away,” she said. “But even the highest mountain, just worrying does not move anything, but if you choose one area and move stone by stone, you pave a way to move the whole mountain.”

So the South Koreans are mobilized and motivated.  And given the miraculous rise of the South Korean economy--actually, nothing miraculous about it, South Korea has simply outworked and outproduced most other countries--we should allow for the possibility that South Korea, on its own, could generate a medical breakthrough on AD.  And of course, were South Korea to accomplish such a breakthrough, the country would have developed yet another export industry, featuring a medical product that could be sold to the world. 

But of course, the South Koreans aren’t there yet, and maybe they will never reach that point--at least by themselves.   Today, the greatest resources for treating and perhaps curing AD are in the US, although there’s shockingly little policy focus on developing a cure here--as Sandra Day O’Connor and two co-authors recently pointed out, we spend 350 times more on AD treatment than we do on an AD cure.   That’s about as penny-wise and dollar-foolish as we can get.   And in addition, hurdles of regulation and litigation are seemingly designed to block progress: the crucial progress of “translation”--that is, turning a bright idea into an effective drug.

George Vradenburg, co-founder of US Against Alzheimer’s, suggests that one way to accelerate progress against AD is to build a “network of excellence” around the world, in which different research nodes--institutes, cities, even entire countries--could contribute to developing the knowledge base needed for a cure, as opposed to mere care.  Such a network is in keeping with the spirit of the Internet, and that’s not surprising, since Vradenburg was one of the visionaries behind the meteoric growth of AOL back in the 90s.   But of course, as Vradenburg is fully aware, the development of such a network would require a significant rethinking of laws and regulations concerning not only liability, but also privacy and intellectual property.  Indeed, since the creation of such an anti-AD network would be so complicated, genuine leadership--public, private, civic--would be required to fully mobilize available resources.   So no, there’s no guarantee that such new networking can, in fact, be realized.

But one guarantee we can make is that progress against AD would accelerate if we could develop a robust AD information network, because as Bob Metcalfe was the first to articulate, the processing power of a network is the square of the number of participants in the network.

And an even firmer--and grimmer--guarantee  we can make is that AD costs will be ruinous if present trends continue.  Not just in the US, not just South Korea, but around the world. 

Meanwhile, back in the US, we can note that three recent deficit reports--one from a presidential commission, co-chaired by Erskine Bowles and Alan Simpson, another from the Bipartisan Policy Center, led by Alice Rivlin and Pete Domenici,  and a third report, from Rep. Jan Schakowsky (D-IL), have all weighed in with ideas for dealing with future deficits--each venturing different ratios of spending cuts and tax adjustments and/or increases.   What’s remarkable, though, is that none of these deficit groups, however well-meaning, seem to have thought in international terms about how to solve problems.  For all the talk about “globalization” these past few decades, our policy process seems strangely parochial. 

What would have happened if the deficiteers here in the US had communicated with the South Koreans about a pooling strategy for AD research?  And with the Japanese?  And with Germany, China, and all the other rich countries that confront rapidly rising AD?    What sort of answers would have emerged from such networked thinking?   Answers including, perhaps, prospects for a cure, or even a significant easing of AD onset?  Or other ideas?   For example, the Japanese are making a huge investment in robots, many of them designed for geriatric care.  The world outside of Japan might not be ready for “geri-bots,” but maybe we will be ready in another decade?

Indeed, what’s so striking about the deficit debate here in the US is how limited it has been, in its intellectual scope. 

And so we come to a paradox: We need to think ahead, and think freely, even as we keep our perspective about what, precisely, can be known.   Throughout history--it has been virtually impossible to see, with any degree of accuracy, what the world will be like 50 years ahead.  So all straight-line projections are bound to be wrong.   That was the fate, for example, of Thomas Malthus, who predicted that England would run out of food in the 19th century, or Paul Ehrlich, who predicted worldwide starvation in the late 20th century.  Of course, it’s not just population projections that are proven wrong.  In 1865 the eminent economist William Stanley Jevons predicted that England would run out of coal in the 20th century and so argued for cutbacks in his own time.  While Jevons was right about the limitations of English coal reserves, he missed the impact of petroleum, which had in fact, been discovered seven years earlier.  Similarly, those today who hypothesize about “peak oil” have similarly missed not only the ever-greater discoveries of coal and oil, but also the emergence of vast new natural gas resources.  

Returning to health, we can recall a US government estimate from 1950, projecting national expenditures for polio by the year 2000 at $100 billion.  Adjusted for inflation that $100 billion would be about $1 trillion today.  Such an expenditure would have been a huge burden on the government and on the economy, but of course, it didn’t happen--because we developed the vaccine for polio back in 1955.

The point here is not to make fun of earnest efforts at forecasting the future--although we might note that many forecasts are not earnest, but rather part of a different political and intellectual agenda.  Instead, the point is argue for a bit of humility, and, at the same time, to argue that in technology issues, the optimists are usually right, at least in an overall sense.  If we allow scientific inquiry its free rein, we will more often than not be pleasantly surprised by what we come up with.

And so the deficit groups of 2010, as they sought to save us from fiscal wreck in 2030 or 2050 and beyond, would have better served the rest of us if they had factored in the best guesses of scientists and medical researchers.   Answers from experts would have been all over the spectrum, of course, but it might have been possible to tease out solutions for not only cutting costs, but also for improving personal health and economic productivity. 

In fact, it would have been useful to include other forward-thinkers as well.   Not because, as we have seen, all forecasts are correct--just the opposite, in fact--but because forecasters and trendspotters can at least point us in the right direction.   And the right direction is technological improvements and productivity growth, which are inevitably coupled with per-unit cost reductions.  

Moreover, this forward-looking consultation process could have been international.  We could have reached out to the South Koreans, and to the Japanese, and others, and said, “How are we going to pool our resources so that we can solve the AD problem?”

Yet instead, the deficit commissions chose to see everything in purely parochial US terms.  And yet absent the transformative potential of technology, the ideas that two of the three commissions--Bowles-Simpson and Bipartisan Policy Center--had for cutting spending, such as imposing the Sustainable Growth Rate (SGR) on Medicare doctors--will never happen, or at least not in any time frame that the deficiteers envision.   The SGR is always pushed back by Congress, because Congress is receptive to the popular demand that seniors should get the best possible medical care, from the widest possible selection of doctors.   An article in today’s Washington Post this morning provides an example of the hard pushback to come; the doctors will almost certainly beat back the SGR, now, and for years to come.

As for the Schakowsky report, calls for big tax increases are similarly unpopular, and thus improbable.

So we get back to an oft-made point: If a big chunk of our population ages and sickens with AD, it will be expensive, no matter what the financing or rationing scheme.  The better answer is to cure the disease.   Such a cure might be a long time coming, but the spinoffs along the way will be valuable, and the goal itself will be even more valuable.