
Vinod Khosla says technology will replace 80 percent of doctors - pella
http://venturebeat.com/2012/09/02/vinod-khosla-says-technology-will-replace-80-percent-of-doctors-sparks-indignation/
======
dmk23
Healthcare technology has always been a siren song for the Silicon Valley. The
thinking repeats over and over:

    
    
      1) It is an antiquated industry
      2) There has to be a better way to do it with IT
      3) My company has the magic solution that will save everyone and make me rich
    

While it is hard to argue with points #1/2 the real problem is finding viable
entry points and building large, growing, sustainable businesses around them.
Regulation, government and professional, is a huge reason healthcare is what
it is.

You can make the best ML algorithm to diagnose and treat disease and doctors
will spend decades arguing about why it is unsafe and they should always be
the final authority. You won't be able to get a diagnosis and a prescription
without them. You might think otherwise, but they have real power in denying
you medical choice via setting professional guidelines through medical boards
and lobbying politicians who are simply not brave enough to pit themselves
against doctor's medical judgement.

It is harder to think of a more counter-productive and self-defeating way to
market any healthcare solution then by saying it is going to "replace
doctors". Here is a great example (DNA testing) of how doctor lobby can
restrict innovation:
[http://www.nytimes.com/2010/03/20/business/20consumergenebar...](http://www.nytimes.com/2010/03/20/business/20consumergenebar.html)

EDIT: I actually believe Vinod Khosla knows better and he just made a troll
statement on purpose. It worked, we are talking about it!

~~~
mtgx
I think a better strategy than to "replace 80% doctors" is to help doctors
"replace 80% of their tasks". So focus on a business that makes a doctor's job
much easier by identifying or confirming a diagnostic, or helping him reach a
diagnostic much easier. The point is to get doctors to _want_ this technology,
rather than fight against it.

~~~
arkitaip
There are worse sources of waste in the health sector. In Sweden, and most
other developed countries I imagine, the introduction of IT has resulted in
less patient time simply because doctors are now legally required to work on
filling out forms, documentation and other acts of IT powered bureaucracy.
What's astonishing is that we don't _know_ if all this documentation is doing
any good, it's just assumed that it does.

So startups don't have to work on hard AI problems to make it big in the
health sector. Removing the bureaucracy caused by IT is a much more attainable
goal _provided_ you're ready to fight policy makers who have created the
regulations in the first place.

~~~
ippisl
But we do know that good IT implementation do help:

"There is significant evidence that CDSS can positively impact healthcare
providers' performance with drug ordering and preventive care reminder systems
as most clear examples." (from a literature review)[1]

[1]<http://jamia.bmj.com/content/18/3/327.short>

------
rogerbinns
The US healthcare "market" is completely distorted ranging from no one having
any idea what anything actually costs, multiple layers of disintermediation
from consumers to payments, a doctor's cartel that keeps numbers low thereby
increasing compensation, but giving an incentive to replace them, income not
based on outcomes, the government spending ~50% of all healthcare money but
everyone ignoring it, and the list goes on.

Atul Gawande's articles in the New Yorker are fascinating insight into how
things really work - full list at
[http://www.newyorker.com/magazine/bios/atul_gawande/search?c...](http://www.newyorker.com/magazine/bios/atul_gawande/search?contributorName=atul%20gawande)

Some highlights:

Reliably delivering care (and cheaper)
[http://www.newyorker.com/reporting/2012/08/13/120813fa_fact_...](http://www.newyorker.com/reporting/2012/08/13/120813fa_fact_gawande)

Pit crews
[http://www.newyorker.com/online/blogs/newsdesk/2011/05/atul-...](http://www.newyorker.com/online/blogs/newsdesk/2011/05/atul-
gawande-harvard-medical-school-commencement-address.html)

Hot spots
[http://www.newyorker.com/reporting/2011/01/24/110124fa_fact_...](http://www.newyorker.com/reporting/2011/01/24/110124fa_fact_gawande)

Costs
[http://www.newyorker.com/online/blogs/newsdesk/2010/12/the-c...](http://www.newyorker.com/online/blogs/newsdesk/2010/12/the-
cost-conundrum.html)

~~~
jbl
One thing I've been thinking of lately is whether there are technologies that
could fundamentally change the incentive structure of the US healthcare market
to be more in line with patient interests. Are there technologies or attitudes
or approaches that could make feasible new business models that would
accomplish such a change?

I don't know, but it's something that's been on my mind.

~~~
rogerbinns
It isn't just individual patient interests but rather everyone. For example
providing sporting facilities at schools and exercise/active activity
facilities for everyone would do a lot to improve overall group health. Making
cities more walkable would do a lot too.

But right now my primary care doctor (who is most valuable to me) gets paid
zero when I am healthy and more the more tests and procedures she does. Other
specialists only get paid when I am referred to them. Drug manufacturers only
get paid when their items are prescribed. Essentially compensation is based on
consumption not on wellbeing which is why the system is so messed up.

The US market definitely needs to be split into two. A baseline coverage that
is based on wellbeing, effectiveness and does take price into account, done by
the government available to all residents. It is easiest to gather the money
via taxes (which already happens to a large degree) and to provide the actual
care via combinations of government employees/facilities and contractors. And
a top up private system where the people who want to pay for or provide gold
plated coverage and procedures can do so (in addition to the base).

Most countries have different systems which amounts to running experiments in
effectiveness and efficient. Heck worst case just do what the French do
<http://en.wikipedia.org/wiki/Health_care_in_France>

~~~
Evbn
Your primary care doctor does not get paid for tests and procedures. Labs and
specialists do.

------
neurotech1
No Vinod. Technology will make doctors more efficient so they can handle 3x-5x
the workload and serve more patients.

I've known doctors/nurses who answer emails both between other health
professionals, and between patients. Sometimes a 2-minute email can take the
place of a regular checkup for somebody with a chronic condition.

Where technology can make drastic improvements is detecting problems when they
are minor, and not becoming major. If a primary-care doctor can only do 5
minute consults, and that results in missing a major diagnosis like cancer,
which is then treated at a later stage, then they've blown out any cost saving
by rushing consults.

------
malandrew
Thinking of innovation as coming from people outside the industry or people
inside the industry is a false dichotomy.

I reckon that one of the catalyzing factors will be smart people who naively
go into school to study medicine thinking that is the career for them, but
drop out of that career path just before, during or just after their
residency, either because they can no longer imagine living the medical
lifestyle or because they realize how backwards it is. Those that drop out
will know more enough about what is wrong with the industry but not have the
horse blinders that those immersed in the industry for years will have.

These people and those who work with the medical industry but are doctors are
the people the medical industry discounts.

------
fingerprinter
The key word here is "eventually". Easy to prognosticate with no timeline.

That being said, technology will likely eventually disrupt/replace many, many
current industries/jobs/practices. This isn't news.

------
ghshephard
The last three times I've contacted Kaiser (In California) to get a doctors
appointment, (Once, when I had stabbing chest pains and my left arm had gone
completely numb - I seriously thought I was having a heart attack) - their
expert system (staffed by a human, still - but that will change) - asked me a
series of questions, and came to the conclusion that I didn't really need to
see a doctor. "Drink some tea with honey for a cough", "Stretch your arm, and
take breaks from the keyboard" for the numb arm. Oh, and "Stress Pains"

So - some significant number of doctors are already starting to be replaced by
the experts systems at Kaiser right now.

~~~
ippisl
Kaiser is a rare gem in the u.s. healthcare system, and the reason is that
they are integrated system: they integrate insurance with treatment.

Since Kaiser if payed a fixed sum and not a fee for service it has motivation
to reduce costs, hence the expert system.

Patients at Kaiser also stay for the long haul(who wants to switch doctors?),
so it makes sense for Kaiser to invest in prevention, and they do.

Finally, Kaiser is an NGO, which i'm sure helps to keep they're priorities
straight.

Maybe Kaiser is a good target for startups ?

------
bfrs
Here's a recent anecdote:

A few months back I got a stomach ulcer and before going to the doctor, I
decided to do some research. I came to realize that the primary cause is not
stress or excess spicy food, but a particular stomach bacteria, _H. Pylori_ ,
going rogue and attacking the mucus lining of the stomach that protects
underlying tissue from the strong acid [1]. _For this discovery, Drs. Marshall
and Warren were awarded the 2005 Nobel prize in medicine [2]_ , as it meant
that ulcers were curable with the use of suitable antibiotics.

However, my doctor (and good friend) insisted that there was no permanent cure
for stomach ulcers and they could only be managed by taking acid reducing
medication (Prilosec) everyday for as long as I lived. I couldn't help
wondering if his information was corrupted by big pharma, who always want to
keep you hooked onto some drug or the other. So, I had to use extra persuasion
and tact to get him to prescribe antibiotics for H. Pylori elimination (and
thus permanently curing the ulcer).

 _I'm a bit skeptical that big pharma's tentacles will NOT reach Watson's
doctor successors [3]._

[1] <http://en.wikipedia.org/wiki/Peptic_ulcer#History>

[2]
[http://en.wikipedia.org/wiki/List_of_Nobel_laureates_in_Phys...](http://en.wikipedia.org/wiki/List_of_Nobel_laureates_in_Physiology_or_Medicine)

[3]
[http://www-03.ibm.com/innovation/us/watson/watson_in_healthc...](http://www-03.ibm.com/innovation/us/watson/watson_in_healthcare.shtml)

------
kamaal
This is because your average doctor is no match to a Google search.

In my own case it has been true. I lost around 35 kgs rapidly to tropical
sprue around 3 years back(By God's grace- I'm healthy now). None of the
doctors could diagnose it. In fact most of them so badly managed my situation,
I had to finally decide to work on it myself. Needlessly to say simply
researching the topic on Google gave me far more perspective than they ever
had.

There were even a few days when I could tell them straight on their face, why
they weren't going with a particular medication with existing ones. I even
described to a doctor how a particular anti biotic works, and why the one he
is giving regularly to patients is not working. I showed them their flaws in
diagnostics, results and clinical procedures.

Nothing that I did was magic. It was all decision procedures, if-else
scenarios with some careful reading and analysis. The point is no doctor hears
to your problems completely. They have preconceived ideas of what your problem
might be and go with that. They cut you off while you are speaking and that is
all it. You are their mercy now. Many of them just experiment with trial and
error methods.

Some just prescribe what the salesman from the pharmacy company sells them.

This is what your ordinary doctor down the lane is. He is not god/super human
who can do miracles to save your life.

10 years into practice your ordinary doctor knows nothing more than what you
would know if you read Merck Manual of diagnosis and therapy:
[http://en.wikipedia.org/wiki/Merck_Manual_of_Diagnosis_and_T...](http://en.wikipedia.org/wiki/Merck_Manual_of_Diagnosis_and_Therapy)

If you can code up that Manual as software- I am not sure if 80% of them can
be replaced. But I can tell you the number will pretty close to more than 50%.

------
rdudekul
I am not a doctor, but I have visited many. With machine learning and big data
analytics, I can see why machines can be better than 80% of the doctors out
there. It may be possible for simple iPhone compatible devices to take the
vitals, send the data to a web service, which returns a diagnostic that is
more accurate than what most doctors can come up with.

It is necessary to stir up the industry with bold statements. Go Vinod Khosla!

~~~
revelation
Vitals are for monitoring you are vital. I'd think they have very little to no
meaning for the majority of diagnoses a GP makes daily. There are many
diagnostical tools where computer analysis can be tremendously helpful (like
EKG), but most of these are very much out of the iPhone-accessory league.

~~~
pragone
I know you were just giving an example, but any practitioner who relies on a
computer to interpret an EKG is not one I would trust. Many times my own EKG
interpretations are far, far more accurate than whatever the monitor thinks is
wrong

~~~
neurotech1
Do you know a primary-care doctor who can properly interpret an EKG? Most
can't beyond the basics. If it is for cardiac diagnostic purposes, then the
recording is sent to a cardiologist for diagnosis.

I have seen a room full of doctors with licenses and who are generally
competent their in practice, who can't read an EEG either. They were not
trained in medical school/residency to read an EEG and so their skill is
limited. The neurologist with an EEG fellowship does the interpretation. This
is after it is digitally processed by software that does the quantitative
analysis.

Note: I am not a physician, but I'm quite familiar with EEG technology
including Quantitative EEG analysis.

~~~
robbiep
An EEG is a very different beast to an ECG. most CAN read an ECG up to a high
level, higher than a computer anyway, because otherwise they would not pass
med school. An EEG is a very different kettle of fish, and it should be noted,
one with a very limited set of applications (ie diagnosis of epilepsy or
advanced scientific reading of brainwaves for interpretation by computer to
perform some function, eg)

~~~
natrius
Do you know how to read an EKG/ECG? If so, can you explain what is involved
that computers are so bad at? Current systems may be worse than humans, but I
don't see why that would still be the case in a decade or two.

~~~
robbiep
Will try to reply to both of these - Natrius - yes but not perfectly -
neurotech - Yes and no I would say... Although your cardiothoracic surgeon may
still disagree, and mine (I am a med student and work closely with
cardiothoracic surgeons) may disagree with me also - it is really about
degree. I would disagree that you can find more information out by a
stethescope although bloods, the 'clinical picture' (what the patient looks
like when they walk/get wheeled through the door) and ECG will all generally
contribute - a stethoscope will not tell you about a heart attack, and an ECG
will not necessarily inform you of valve abnormalities which is what you are
listening to (although you may detect things like ventricular hypertrophy that
are caused by Aortic Stenosis etc)

There is only so much useful information you can extract from an ECG. What I
mean by this is that for the primary care physician, the information that you
want to extract is: are they having a heart attack, do they have major
electrolyte disturbances, do they have an abnormal rhythm that we need to
shock them out of now; is there evidence of previous myocardial infarct? -
these influence immediate management in the emergency room; if there are other
abnormalities then if the problems are localised to the heart a cardiologist
will generally be called, as, like any field, there is a significant degree of
specialisation once you move beyond the specifics.

Natrius: what is a computer bad at? I'll try and explain as best I know how:
1st Degree heart block? Easy (P wave more than 200ms) 2nd degree heart block?
again, fairly easy. just a matter of timing. computers can handle this easily
as well as it is simply a measure of difference between 2 different
amplitudes.

3rd degree heart block, again, pretty straight foreward.

Myocardial Infarct (heart attack) and ischaemia: relatively straightforward
for a computer and human to read as there are 'voltage criteria' that
determine if the heart is starved of oxygen or not; basically to do with the
time for repolarisation of the heart muscle in the presence of 0 oxygen.

Systolic Tachycardias - straightforward and easy to see just vusually. Same
with ventricular tachycardias.

Various electrolyte abnormalities - get a bit more difficult. different waves
start to blend into each other. These can be quite non-specific and can mimic
other abnormalities. Partially this is because they cause such strange changes
to the electrical activity in the heart, which changes the de/repolarisation
of the muscle, which changes the look of the electrical activity. also, shifts
in one electrolyte will often lead to shifts in others, which further muddies
the waters.

In general, The easy stuff (based on voltage criteria, times between peaks and
troughs) etc is relatively well handled by computers; some aberrant rhythms
trick them, and electrolyte changes or waves that look as if they are abnormal
give the computer nowhere to go - it doesn't know what to call it so calls it
'abnormal rhythm' - basically it would be up to the clinician to combine the
clinical picture, ECG and blood results to get a diagnosis and correct.
additionally, ECG readings and interpretation may be complicated by previous
infarcts, chest wall deformities, 'dextrocardia' - heart on the other side of
the chest; about 1:10,000, and incorrect lead placement.. Can it be improved?
Sure. In fact there are some studies that suggest that it might even be
possible to predict heart attacks from fractal analysis of ECGs several days
out from the actual event (this is kind of like fractal analysis of
earthquakes and I know very little about it... neurotech you may perhaps know
about some of this when used with EEGs? I have heard it is useful there too)

hope this helps your understanding

------
carbocation
Challenge #1 is to get sufficient data. There are surprisingly few medical
data available that have sufficient parameters to let you do any useful
training.

------
elemeno
I'm always somewhat leery about these sort of predictions since to my mind
they seem to miss that being a doctor is often more than just making diagnoses
and deciding on a treatment - it's also about having a relationship with the
patient, especially when it comes to primary care practitioners (like GPs in
the UK) and specialists for long term conditions (such as my father, an
oncologist, who has patients he's been seeing for ten or fifteen years since
their initial diagnosis and treatment).

Not withstanding that people are generally more comfortable and willing to
submit personal information to a fellow human who they know and trust, there's
also things like how does a computer tell the difference between a little old
lady with a problem, and a little old lady who's just lonely and uses going to
her GP as a way to get some human contact every few weeks. Her GP will likely
know the difference though, because she's known the little old lady for the
last five years and has realised that her visits aren't about the vague
symptoms she's presenting, but the ten minute chat she has with the doctor.

~~~
ippisl
>> people are generally more comfortable and willing to submit personal
information to a fellow human who they know and trust

There was some research(can't find it now) , that show that filling an
automated form is a good way to make patient elicit personal embarrassing info
that they wouldn't offer via chat.

>> difference between a little old lady with a problem, and a little old lady
who's just lonely

First that's a nurse can easily do. And maybe, hopefully we'll find ways to
solve the loneliness issue.

------
pragone
I look forward to the day that machines can practice art the way doctors do.
One of the most underrated/underappreciated aspects of being in medicine is
realizing it is a true amalgamation of art and science, relying heavily on
both education, experience, wisdom, and instincts.

~~~
guylhem
Being in medicine, I don't agree.

Over 80% of the job could be done by properly designed algorithms - and 80%
would be a conservative guess. The "interesting" cases are very rare, and
mostly consist in easy-to-do diagnosis of unfrequent illnesses (I once
diagnosed an insulinoma! hurrah!)

Just look at the growing number of tasks given to non-MD- say RN. It's a trend
that will go on.

Human knowledge is nothing but the application of algorithms - deciding which
symptoms are important, which are to be discarded, which require more
investigation, etc.

Education is building algorithms. Experience is machine learning. Wisdom is
statistics. Instinct is prioritization.

The faster we can implement all that in software, the better.

~~~
ippisl
hurrah for insulinoma diagnosis:)

I think that even rare disease diagnosis can be done better by algorithms by
using Isabel healthcare's diagnostic system[1] or Watson(in the future).

The place where a human will contribute the most is the interpersonal
stuff:motivating people, digging data from people(although computers compete
there[2]) and administering placebo.

And of course doing the physical stuff.

But that seems very different from the job of a doctor and closer to the job
of a nurse.

[1]<http://www.isabelhealthcare.com/home/default> [2]There was some research
that showed that people give more personal information to a computed form than
via face to face chat with a doc.

~~~
guylhem
Agreed - algorithms won't just plainly discard rare diagnosis the way many
physicians do. (especially at 3 am :-)

Of course, it should never be top of the list - unless it becomes a
possibility given the accumulation of negative results of other tests for more
common diseases, or the positive results of DNA sequencing.

Unfortunately, that's not the way it will happen with an human : rare almost
means "ruled out" simply because "poorly taught" or even unknown, and for the
best of us "get a second opinion with xxx who specializes in this very
disease".

DNA sequencing is at most used for a couple of diseases per specialty, and
data mining/fishing expeditions are frowned upon (maybe rightly so given the
human bias of trying to find meaning and correlation in what may be
unrelated).

I strongly believe the beginning of _true_ e-medicine will make us look at the
current medicine the way we look back at blood letting, holy waters, the four
humors imbalances etc.

------
vineet
As an investor, Vinod Khosla's job is to make such bold statements. But his
statement will never come true.

Even if you assuming that 'doctors' and 'humans' are old technolgy, whenever a
disruptive technology has come to market the old technology has not gone away
-- it is still used and is often a part of a growing market (this is partly
why incumbents are often so slow to move).

Regardless, I think the right way of phrasing the above is that in the future
80% of medical needs will be met by technology. This statement is actually
different from implying that 80% of doctors will loose their jobs, it is more
that technology will help them do their jobs - either to service more people
or to service more complex situations.

