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Book Reviews

Silicon Valley To The Rescue, Version 2.0

One of the unsung pleasures of writing a book for commercial publication is enduring the "more marketable" title a publisher will foist upon your book, often in the eleventh hour, long after you have lost all negotiating power. I am hoping, for the sake of Andy Kessler’s intellectual integrity, that this is exactly what the folks at Collins did to his latest, The End of Medicine: How Silicon Valley (and Naked Mice) Will Reboot Your Doctor.

Although Kessler stops just short of actually admitting it, The End of Medicine describes nothing of the kind. Rather, this occasionally amusing but mostly sophomoric romp around the high-tech fringe of medical technology by a former Wall Street money manager proves exactly the opposite: The end of medicine is nowhere near, and Silicon Valley, despite a new generation of money and mouths flooding the health care information technology (IT) community, will not be changing anything about medical practice anytime soon.

Kessler’s quest is quite simple: Can society find and finance technologies that will help medicine "scale?" (namely, help it utilize technology to reduce human labor and increase efficiency). From his previous work on Wall Street and in Silicon Valley, Kessler has seen the economic power of IT that grows exponentially cheaper as it is deployed. He has witnessed not just the social and economic progress, but also the enormous wealth that flows from a plummeting in unit cost, for everything from microprocessors to cell phones, through what has become widely known as Moore’s Law, or the geometric expansion of computing power per dollar. Why, Kessler wonders, can we not effect the same hyper-economies of scale in our medical care system? And can IT liberate the current medical delivery system from its labor-intensive, inflationary nightmare? These questions might not be as old as the history of computing, but they are certainly as old as the history of managed care and worth asking anew.

The opening bit in Kessler’s first-person narrative is wearyingly familiar: A healthy, middle-aged patient confronts mortality for the first time, and so he confronts the primary care system, seemingly also for the first time. A classically harried primary care physician runs through a quick physical, orders the usual tests, and then gives Kessler classically equivocal advice about how to deal with his elevated cholesterol. To treat or not to treat, that is the 100-billion-dollar question, one we health care lifers have been grappling with for years. Kessler is of course outraged (especially given the absence of sound medical evidence to support the heady markets he and his friends have helped prop up with capital for decades) and decides that the entire health care system is a scam.

This is, to be sure, the perfect place to start a book that seeks to reboot the entire system. Along with warring schools of thought about hormone replacement therapy for women, whether or not to medicate asymptomatic patients with high cholesterol is one of the great known-unknowns not just in medicine, but in all of medical economics and public health. The seemingly willful absence of unambiguous answers about these enormous and enormously expensive clinical questions is an embarrassment to us all and could have provided Kessler with the perfect springboard for a tirade against the separation of science and clinic, or a sermon on the need to standardize and mobilize evidence, or, at the very least, one more infomercial for the belated computerization of medical decision making.

But immediately after the opening episode of a book that purports to explore the "rebooting" of doctors with technology, Kessler flees the primary care clinic and all the medical floors and instead spends the bulk of his time down in the shadowy world of the radiology unit, watching radiologists read diagnostic images. He marvels, as should we all, at the still wildly imprecise, almost ethereal nature of reading those images from the nether-world within: its extant artfulness, its continued reliance on the exquisiteness of human cognition, and its seeming imperviousness to machine replicability. But confronted by this clear threat to his tech agenda, Kessler goes into classic Silicon Valley health care denial. He spends nearly the balance of a book advertised as "the end of medicine" in long, rambling explorations of various diagnostic imaging technologies, where they might one day lead us, and how they might one day actually replace a doctor or two. But instead of drawing the obvious conclusion—that IT will ship this stubbornly human physician specialty across the ocean on the other end of a broadband connection—Kessler loads up his book with better and faster core diagnostic technologies.

Then he misses the only point relevant to his own hypothesis: Such technologies will, inevitably, require more physician labor to mediate, not less. Instead, he treats us to a series of "gee whiz, that’s complicated" interviews with physician-researchers/computer scientists—none of them written with any of the - precision, balance, or skepticism we would expect from the typical Time or Newsweek article - on the same subject. In his search for better and faster, which often coincides with smaller and more precise, Kessler takes us on a tour of diagnostic technologies that seek out previously undetectable brain aneurysms, coronary artery occlusions, and miniscule but menacing colon cancers. As champions of public health - and ultimately patients ourselves, this is exactly what we want from our medical technologies. But do they really scale? Will they "end medicine" as we know it? Will they "reboot" our doctors?

Of course not. If techno-evangelist Kessler had Googled any actual health services research, he would have discovered that faster and better diagnostic imaging technologies not only will not replace radiologists but will actually increase the need for radiologists to cope with the wealth of new patients eligible for (or at least demanding access to) the new technologies. He also would have discovered an increased demand for nearly every other kind of physician, downstream of those new technologies, to cope with all the false positives; to perform all the biopsies and other diagnostic surgical procedures they would inspire; to treat the complications and sequelae from all those new interventions; and to initiate ever earlier and aggressive medical and surgical treatment on asymptomatic patients who would have muddled along until their previously undiagnosed condition erupted and killed them. Now that’s how to scale a health care system.

Kessler’s lack of sophistication regarding this conundrum is commensurate with his prose. The End of Medicine’s rambling, dialogue-driven descriptions of new medical technologies are amateurish and uneven—a problem not helped by Kessler’s writing style, which ranges from sloppy, to irritating, to offensive. "Staring at mammograms with a 70-year-old radiologist," he writes in a typical aside, "is probably not considered, er, titillating" (p. 103). Along with repeated references to "artificial anal sphincter" (for comic effect, perhaps), a bowel obstruction lecture "given by the aptly named Dr. Chow" (p. 120), and myriad other juvenile jetsam, this may be the first book reviewed in a serious policy journal that could claim as its literary inspiration the cable TV show Beavis and Butthead. Kessler’s grammar would certainly corroborate such inspiration, as witnessed by this masterpiece of a sentence: "If technology was going to somehow fix health care, I wanted in" (p. 28).

In a rare moment or two of lucidity, Kessler actually admits that some aspects of medical technology might not scale in ways that would increase diagnostic certainty and reduce costs. This he discovers during side trips to pharmaceutical-testing labs, where he watches several apparently personality-free scientists tricking mice into growing cancers and screening chemical compounds for new cures. In one of his many asides, watching the arithmetically scaled ritual that is the drug discovery process, Kessler accidentally stumbles onto the harder truth at work well beyond his facile thesis about technology and doctors: "It’s really systems biology that matters," he writes. "You can digitize some of it, but still not understand the entire system—like how is it possible that there are over one million proteins in the human body but less than 30,000 genes?" (p. 148).

Here, The End of Medicine inadvertently introduces us to the real underlying reason why doctors do not scale and medical knowledge only exacerbates our awareness of our ignorance: complexity theory. There are too many human, physiological, phenomenological, and raw scientific factors involved in the actual practice of medicine; the closer we look at the miracles of our own bodies and minds, the more confused we become, and the more we want the human reassurances that only hands-on doctoring can bring. This is the bitter pill that managed care choked on for more than a decade before giving up and simply increasing copayments for physician visits. And this is still the reason that public and private health plans alike have always treated new medical technologies as if they were guilty of inflating costs until proven innocent. Simply stated: Diagnosing more does not necessarily mean curing more, but it does mean that we have more to treat.

Thanks to his epiphany in the drug lab, Kessler realizes that "it was a giant crapshoot with shareholders’ money" (p. 148)—not exactly news to any serious investor in drug or biotech company stocks. His entire hypothesis thus threatened by his actual observations, Kessler throws up his hands and heads back to the radiology department, treating us to yet another lesson in geometric scaling of computer chips designed to diagnose more diseases for which those arithmetic labs may or may not ever be able to find effective drugs.

However, health care, like history, does seem doomed to repeat itself. If the current gusher of health care IT investment capital runs down the same black hole as the last one, AOL’s Steve Case and his Revolution Health Care will most likely be sitting in for Jim Clark and his dot-com disaster, Healtheon; Kessler’s The End of Medicine will prove to be a crude new version of Michael Lewis’s Y2K classic, The New, New Thing; and you can tell your children to go to medical school anyway, because the coming IT revolution, like the one before it and like the managed care one that nearly survived both, will not be happening anytime soon. Med school might not make them as rich as Andy Kessler and his Silicon Valley friends, but when they graduate, they will still have jobs, nobody will be "rebooting" them, and they will actually be making a useful contribution to the U.S. health care system.

J.D. Kleinke

Editor's Notes

 
J.D. Kleinke (jdk{at}omnimedix.org) is chairman and chief executive officer of Omnimedix Institute, a nonprofit health care information technology research and development organization based in Portland, Oregon.

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