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Why Are Medical Ultrasound Systems So Inexpensive? (liesandstartuppr.blogspot.com)
117 points by skybrian on Dec 22, 2016 | hide | past | web | favorite | 71 comments

This is a great post, thanks for writing and sharing.

I'm a biomedical engineer and found both posts interesting.

There are really exciting things happening right now where the murky area between expensive, slow medtech and fast-moving, lower cost consumer products are being explored.

There have been some specatular implosions of approaches straying to far towards the consumer tech-startup approach.

Like most things, the best path is probably somewhere in between. Medicine and health is hard because the systems involved are complex and non-linear. There is a higher burden for doing things right than other industries. That said, people also suffer from innovation being slowed by red tape and leading to increased costs.

One great but unlikely solution would be for an improved market for used equipment, where the device loses its certification for medical use and obsolete software becomes open source. Little incentive for manufacturers to do this, but would be great for hobbiests, more 'wellness' rather than medical applications, and improved use in developing countries (where used medical devices like ultrasound machines often are donated but aren't used, because they can't be adapted to local needs).

Original post author here, thanks for your comments.

There is a robust second hand market for ultrasound systems and probes, just google for those companies or search on eBay.

There are also research platforms out there for imaging from various universities, some of which are open source. They aren't nearly as good as the commercial codes, but a few grad students can't compete against teams of full time professionals working for decades. Commercial codes are unlikely to be open sourced. Many are tied to the architecture of the systems, and most are reused in later systems and so are still useful decades later. It's highly unlikely that any company would open source them, it's just not how they operate.

As for explosions of technology and advances - yes, I do expect more advanced electronics and signal processing to have a large impact on ultrasound in the coming years, but it is more complex than most in this thread give credit for, and will take time to appear.

I trust the current post on the physics and EE side of things. That said I'm also very curious about the computer graphics side nowadays. It seems to me that historically, most of the complexity was handled through sophisticated mathematical abstractions at the material level, making the research very costly. How much post processing can be done to infer more information from less costly inputs (I'm thinking ideas like Super Resolution used in spatial imagery). Nowadays very very powerful GPU chips can be found for not much and could be used at this part of the process. Maybe you heard about such ideas, I don't know. I've seen NVidia involved in computer vision for the medical field, but not a lots filter through to me.

There is work going on in this sort of arena, and I've wondered why there hasn't been more. I think probably there are a few reasons.

First is medical imaging tends to have relatively low resolution and high noise compared to optical images. So there is a danger of over-processing.

Second is, somewhat related, that I think there is distrust in clinical practice and regulation of black boxes where processing happens in the background. You're taking responsibility away from a doctor and putting it on your system, so there is a greater burden of validation.

Third is cultural. Doctors get a ton of training to interpret the signal in these images, and I think there is both a badge of honor in this as well as a barrier to adjust to something new. In my Masters, one of the medical device design instructors talked about a prototype of a digital stethoscope with huge improvements to acoustics. Doctors hated it - even though the sound was better, it wasn't the sounds they were used to. Although this was before the Eko Stethoscope, which is a digital stethoscope and seems to be doing well. Maybe an example of market timing.

Quick answer - yes, GPUs are now reaching the point that they are becoming useful, but also imaging techniques such as superresolution methods, ultra fast imaging, and others, demand even more computation. I expect to see advancements in the next few years because of this, and at some point (maybe 10+ years from now), that GPU power will exceed the demand from ultrasound and even the highest end systems can use them for all needs. This is not lost on the community and they are working on exactly that kind of research.

There are improvement in modes that have been recently achieved thanks to the computing power available in CPU or GPU. For example you can now see the microvasculature with far more details than before on some systems.

The article seemed to be mostly an explanation of why any high quality ultrasound has to be expensive and I'm sure the author is correct there. But the original article was about the possibility of cheap, low quality ultrasound.

I can understand why, when you're dealing with human lives, you wouldn't want anything but the best. But that wasn't the use case of the original article.

Yes, I think the author's criticism of the original article is a bit harsh and misdirected. There are lots of caveats and qualifications in the original, including the frank admission that the transducers are difficult and expensive to make. It also includes explicit statements to the effect that a cheap ultrasound machine is not intended for serious medical use but rather for "education, imaging, sports training and just for fun."

Yes, I think you are right.

Also, I'm curious if good software can somehow compensate for low-quality hardware. The availability of a cheap machine could spur the development of new signal processing algorithms that work around hardware shortcomings.

Is he correct, though? Even a high quality ultrasound probe is only a few thousand dollars. At best, <5% of the price goes towards the probe. The price inflation is absurdly high regardless.

I don't like this post because it just plays up the difficulty of the engineering without any context. Yes, making an ultrasound is hard and complex, but its not as hard and complex as making a car, which is how much they cost. He just presents the engineering like we should be able to intuitively relate that to cost.

Hell, he also doesn't contextualize any of the engineering itself. At the end he brings up the housing, and not making it cut or burn people. What? Not making things sharp is not rocket science. The machine doesn't cost 30k-150k because it isn't sharp. Most things aren't sharp. He's conflating details with challenges.

Acoustic lenses, 100 micron precision? Injection molding produces surface finish and repeatability to sub-micron levels without even trying. A 50 cent plastic magnifying lens is more precise than the acoustic lens in an ultrasonic machine, AND its made of more expensive plastic (it just so happens the best acoustic matches between water and PZT are very cheap plastics).

He's completely dismissive of PZT buzzers, which is really unwarranted. A 2 cent PZT buzzer is actually the closest product to an ultrasound probe, engineering wise. The transverse mode of a PZT buzzer is in the tens of MHz, the surface finish is easily a few microns, and the performance across the disk is very uniform- it just so happens the cheapest way to mass produce buzzers creates those properties. Of course to get two disks that are similar you need to pay more, but the price is still measured in cents.

Dice and fill is complex but not necessary, especially for lower frequencies. It uses standard semiconductor tooling and while expensive, it doesn't mean each transducer costs as much as a car. Splitting the elements is also complex, but its a hell of a lot simpler. Also he keeps saying 100 micron- its not a feature size except for dice and fill. It's an accuracy, and one that can be achieved by hand with 2x magnifiction. For actual context: 127 microns is your standard "sloppy" machinery tolerance. When you order something from a machine shop and mark a dimension as not important, you'll get 127 microns/.005".

There are any number of ways to section the transducer. Laser would be one. It would cost less than a dollar per, and worst case you have to repole the PZT afterwards. Bonding is a pain but not complicated. You can just solder to silver coated PZT, strain relieve the bond wire, and pot the whole thing in plastic. Keeping that 100 micron accuracy just means making sure you don't get hair all over it when you put it together, unless you're blond in which case your hair is too fine to matter.

And then... a cable? That's his next example of complexity? Buy a bunch of ground plane ribbon cables and roll em up. Crosstalk will be less than on a PCB. This whole thing just gives off the impression he's stuck thinking about things the way he's always done it and has never considered alternatives. He talks about the challenges of building products.

>Ever made a protoype? Ever made 2 of them? 4? 100? 10,000? And made them all the same? Yep, it's a different world when you have to start selling and supporting products.

It's one thing to make a product that doesn't inject noise into the hospital grid, is shielded to more than FCC standards, its waterproof and heat and fireproof. It's quite another to just make a product. Yeah, making things is hard, but literally every company that sells something knows how to do it. It's built into cost. It's not an explanation.

A 2 cent PZT buzzer is ridiculously far from an ultrasound probe, engineering wise, and your units are off by about three orders of magnitude. And soldering depoles PZT.

A transducer does not cost as much as a car (well, not a well made car), but a system does. That's the cart plus a number of transducers.

Yes, I only covered the transducer in that post, but as I noted, the systems and software deserve their own Pt II. It takes time to write this kind of stuff you know?

Your other points I try to answer in my updated blog post along with many others here in this thread.

What units? Thickness mode resonant frequency? The cost? injection molding precision? The 100 micron thing? I have a PZT buzzer on my desk that I measured the thickness resonance, which is 5 cents in units of 10k. Injection molding accuracy is around a thou, but the precision and surface finish is impeccable. I also have on my desk parts with 0402 resistors- 500 microns wide, 350 microns tall. I soldered them by hand without magnification. 38 AWG wire is 100 microns wide. 100 microns is wide enough to drive a truck through.

Soldering with silver-lead depoles PZT. Bismuth solder does not and regardless repoling PZT is trivial- a couple hundred volts at most, and temperatures below the melting point of plastics.

The transducer is the only part of the system that should concievably be expensive, though. Doctors don't use special, medical-company made laptops- they use thinkpads or dell or whatever. The cart is unnecessary! It shouldn't be where the cost is coming from. The cart should add a few thousand dollars. The electronics have no business costing tens of thousands of dollars. The R&D, the software, and the transducers are the only plausible money sinks. If making a monitor is expensive, the companies should buy a cheap laptop and write an application to run on it.

I do really enjoy your posts but I am firmly in the camp that the price of ultrasound machines is an order of magnitude too high. I also think it needs to come down ASAP and that the future of cancer treatment really depends on regular ultrasound screenings and machine learning.

Edit: also, to back up my statements about the electronics: https://news.ycombinator.com/item?id=13245998

Philips is offering the Lumify at $199/mo https://www.lumify.philips.com/web/

The device is used with a mobile and is portable anywhere. I found it has an excellent value-proposition and potentially revolutionizing the space

Interesting that they are selling the hardware as a subscription, although they also seem to offer it for actual you-really-own-it purchase, but I couldn't find the price for that: probably the equivalent of three years of monthly fees, so around USD 7k, maybe a 25% discount to be competitive, so USD 5.5k for the hardware plus the app/support/whatever. It certainly isn't five grand of electronics though. I'm assuming from the looks and size of the device that its just the transducer and an ADC/DAC streaming to/from USB, so based on the earlier HN article perhaps less than USD 1k for it if you were to try and build the thing yourself?

> A subscription or outright purchase includes a Lumify transducer, the cloud-enabled Lumify Android ultrasound app, software upgrades, manufacturer's warranty, and access to Philips service and education

Sadly it only seems to be available in the USA. I'd love to have my very own device that lets me look inside myself; a paltry two hundred bucks seems pretty reasonable! I think you'd get bored looking at your spleen after a month, although I wonder if drunken 'let's look inside Bob's lower intestine' (can you do that?) moments in the pub might never get old... Also great for checking if the toddler really put that marble up his nose, or checking the progress of the priceless gold C3-P0 LEGO minifig he/your dog ate.

It even does doppler imaging, so you can watch blood flow in your veins - the first time I saw this demonstrated on me in hospital I was amazed, it's pretty cool. One thing it does is colour the flows red or blue, depending on direction, but interestingly since it has no idea which is really an artery and which a vein, the doctor has to decide visually and flip the colours if appropriate.

How does it compare to the ultrasound machines found in hospitals? (if that question even makes sense)

It's not really intended to replace full scale machines but it is a big step up from the cheaper imaging solutions available in the past. It is ideal for "first aid" style situations, and will probably see widespread adoption in ambulances soon enough.

I would like to see the author's reaction to this product.

Have you used it?

Sh$t I wish I knew that last year ...

> If you can really build an effective ultrasound system that people want to buy for significantly less than the currently available price when you've no expertise in the field, then why hasn't someone else with vast experience in the field gone and done exactly that?

If you just made a new effective ultrasound system that passes the FDA, why would you sell it for a lower price when you also can make more money?

> If you just made a new effective ultrasound system that passes the FDA, why would you sell it for a lower price when you also can make more money?

Because you have an ideological desire to make ultrasound available in the developing world.

EDIT: There are a number of large, wealthy, organisations that have this desire - to improve the quality and availability of medical stuff in the developing world.

They have enough clout (and money) to bring a cheaper device in.

If it was below a certain threshold of personal investment I totally would (not saying I'd release something useless or dangerous carelessly out of hubris). I would love more accessible non invasive monitoring tools. I personnally suffered from nasty yet transient issues, that vanished enough by the time I went to my MD but were recurring for monthes.

I don't buy the money argument, price is not cost. I'm fairly convinced that the medical market is inflated at every level, ending on a premium. Ultrasonic devices may be as complex as he says, the dude is a reference. But I've just seen firefighters portable EKG monitor that they say cost a fortune, and it's mostly crap. Very bad cell reception, couldn't send data to the doctor. Not as sophisticated as an US echographer, just 7 probes, a LCD in a sturdy/friendly case; still pricey.

I'd bet a few dollars that any electronic company today can make something affordable, with better connectivity. It's just that the market allow for such prices.

You would sell it for a lower price to gain more customers than competition.

Medical equipment is more or less a fixed market unless you are going to sell to developing nations and even then the cost of the machine might very well not be the factor.

Hospitals, clinics and medical staff as well as the infrastructure required to support the machines are your limiting factor.

With portable devices that can hook into a laptop or a tablet it's not much of an issue but still there will be a hard limit for the market and it's considerably lower than you would think.

You also need to understand that the lifespan of some of these machines can be decades so in effect if you make it too cheap you either have to build in planned obsolescence or you'll sell yourself out of the market.

You're assuming the existing customers are price sensitive.

Not necessarily. There is a certain optimal point of price and demand. It's entirely possible that the limited supply due to all the barriers to entry allows even a range of competitors to price their products well above their own costs or the minimal costs in their industry.

It's just not true that multiple competitors have to collude to keep prices well above the perceived minimum costs. Or that collusion is a conscious process, either.

Because there are multiple competitors in the field, and you are a new entry. In order to be accepted as an unknown in a quality and results conscious market, you either have to be way better, way cheaper, or some combination of those.

If you are an established player, then you can sell for slightly less and get market share from your competitor. But in a competitive market, he is also smart and makes the system cheaper, then undercuts you, and on it goes until price reaches equilibrium at a much lower price point.

If you are in a monopoly position, then you can extract a premium profit until either the govt stops you with anti-trust, or a competitor appears who wants some of that profit. If you listen to everyone on this thread, ultrasound systems are easy to make so jump right in!

Ultrasound is an incredibly competitive market with multiple large players, each of whom has high quality technical teams and they compete for market share.

In case anyone is interested, there are low cost (< $10k) portable diagnostic ultrasound machines. I used to work for a company that made interconnects for medical devices, including ultrasound cables. Sonosite was developing their portable systems back then - 15 years ago - so low cost systems aren't something completely new. They don't have the same capabilities of full ultrasound systems, but they do fit the needs that some people are discussing here.

I have used a similar machine. It was purchased used for about $3,000 for a pregnancy resource center. And as a Test & Measurement EE experienced with some high-density analog cables, I was extremely impressed with the quality of the cable in that device.

But reading your post and this one:

> ... and then it's got to connect to the cables off to the system - all 100 to 200 wires down a cable that's a couple meters long, and thin/light enough for someone to use 8 hours a day without getting repetitive strain injuries. Do you know how thin that makes each wire? Try calling a few cable vendors and ask for a small diameter cable with 200+ connectors that will actually conduct a signal without significant crosstalk and let's see where you end up on price.

It also mentions the system being mounted on a cart. This seems like an area where technology can make some serious improvements. Mount your ADC (for which speed, accuracy, power requirements, and channel counts have been steadily improving) within the probe, and stick a high-speed serialization/deserialization chip on the other end of it, and run power and digital data over a much smaller, cheaper cable. That's the direction that industrial I/O is going, at least.

I guess the point of all this is that there are opportunities to make significant changes to the way these devices operate that will make them easier to build. Switch out the ASICs for GPUs, the analog cable for digital, the custom computer for commodity hardware, and so on because these technologies are more capable than they were in the past.

That advice is so good that people are already working on it... even in the past!

Believe it or not, there is no plot for using outdated technology and keeping the prices high. This is a quite competitive market, and engineers working in the field are not stupid. There are already some machines using GPUs for the signal processing. I think there might also be some machines with ADC in the probe, although this is not simple (you also have to put the transmit side, and the rx side has to be of good quality) and you can really benefit from extremely high acquisition rates, so depending on what you want to do such a digital link is not trivial + plus you basically duplicate a large part of the machine in each probe if you do that, so I'm not even sure this will be better in every cases...

Also; a new machine can take several years to design and bring on the market.

Exactly, thanks for putting this so succinctly.

I mostly agree with this author's post but I think the 'I just want to play around with this' vibe of the original post mostly missed.

So yes - those things are "expensive" (in the 'it's a lot of money' sense) but "inexpensive" in the (stuff is hard to build and takes some knowledge and parts).

But I feel reminded of those cheap 60 bucks tablets that are not high end and fail all the time for various reasons, but if you just want a wall-mounted touchscreen why would you buy an ipad instead of one of these.

Good point but i don't think it applies in the context of a medical device.

The transducer is one thing, also the electronics are highly non-trivial, to the extent that it is in my opinion the most complex of the big three medical imaging techniques used.

With CT you have some large mechanical thing, pretty much straightforward X-ray source and image sensor, slight issue with interconnect between the stationary and rotating part (that only has to carry power and digital data) and bunch of software.

With MRI you have large superconducting magnet (which is expensive, but not that complex), few power amplifiers for various coils and relatively low bandwidth RF receiver and then bunch of software.

With ultrasound you have the transducer head, which is connected with specialist flexible multi core RF cable with the frontend. Frontend has to be able to both supply large (essentially RF) power to said transducer and listen back for reflected energy with as little dead time as possible and with as low SNR and wide dynamic range as possible (and typically using the same physical wire to the transducer for both Tx and Rx path), with this whole frontend being replicated few dozen times.

And all for ~1/10th of the cost of a CT or MR system.

It would be nice to have cheaper ultrasound devices, and yes, it can't be that hard to develop something which is useful to a certain hobbyist niche.

Especially with pet breeders, I could see a use for devices around a couple hundred Dollars, though there may not be enough demand to warrant commercial development, especially not from players interested in selling more expensive, over-engineered (for this purpose) devices to the same market.

It's clearly not easy to break into the market for USI, both at the low and the high end. But with patents expiring, and electronics becoming cheaper, more customizeable, more performant, the bigger players may have another think coming.

This was good. It's good to be reminded of the complexity of things we might overlook.

However the answer to any question around why something is expensive or not is economics, specifically supply and demand, marketing and distribution channels, and barriers to entry.

This is the technology sector. We have made a cottage industry out of taking things that used to be at the maximum level of complexity and turning them into household items. You could write a similar article about how web servers work -- there's an amazing amount of complexity in there, but we've commoditized all of it. Ultrasound tech will follow the same trajectory, although I have no idea how long that will take. In addition, ultrasound providers are marketing towards large, rich, healtchare providers who are operating in a tightly-regulated market. If I had a $1,000 ultrasound that only worked for a year, was quirky, might scald me or my patient, but was good for quick diangoses in the field in third-world countries? It might be all I would need. There is no universal "ultrasound" device that has to meet a ton of specs. That's just the way the market is configured currently.

Good article. Lots of cool stuff in there.

Why is it ok to scald patients in third world countries? What if the quirks lead to misdiagnosis etc? If there was a way to produce this technology safely and cheaply people would be doing so

My point was that it might be better to accept a risk of scalding if it saves lives. A really cheap ultrasound could have all sorts of bad attributes -- and still be worth it to the people who are using it. It could make an incredible positive difference in people's lives. There is no universal set of standards. It varies a lot depending on particular circumstances.

If risk of scalding means the price can be reduced to a point to where every ambulance or high-speed paramedic car can have one, then it is worth it. If it means that every back-water third-world doctor can have one, great. Sometimes knowing if a patient has internal bleeding, and where, is worth the risk.

Don't forget to balance that advantage with the risks and harms of over testing.

Curiously, cheaper ultrasound is at the heart of the proposition of a "new" player in the field : Butterfly Network.

I'm a doctor who is qualified in echocardiography and other ultrasound techniques, teaches ultrasound to other doctors, and who uses machines from multiple manufacturers regularly. I've also been computer programming, and generally interested in comp sci, for 30 years.

My 2 cents worth on differences between more expensive vs cheaper ultrasounds, how ultrasound has changed over time, etc is: * ultrasounds are getting cheaper and better. Harmonic imaging was probably the biggest advance for me. * because of cheaper, better machines, many more doctors are using ultrasound than before. A real challenge is making sure they are appropriately trained to use ultrasound to get the most useful images, that they appropriately interpret what they see, and recognise their own limitations. The results you get from ultrasound are highly dependent on the training and experience of the operator, more than most other imaging modalities. Although some techniques are easy to learn, many require substantial training and experience. Putting ultrasound in the hands of someone who doesn't know how to interpret the findings is not risk free. * there is a significant increase in image quality and the modalities available with more expensive machines (although this does not seem to be a linear relationship over the range of price; once you get into the top echelon of machines, differences in cost between them doesn't necessarily correlate with their capabilities). * With more challenging assessments, these differences in image quality and modalities can mean the difference between a diagnostic and a non-diagnostic scan, and change management and outcomes for patients. However, there are some techniques (e.g. vascular access) where entry level machines are usually adequate, particularly if you have access to a better machine for challenging cases.

Although I'd love to see the quantum leap in imaging quality that some startups are apparently aiming for, I'm not holding my breath. That doesn't mean I don't see a lot of potential for technology to improve though - some things I expect or hope to see over the next decade or two are:

the application of computer vision and machine learning techniques to assist with the interpretation of scans. This is already happening a bit (e.g. strain imaging, automated 3D ejection fraction) and it's an active area of research. It has the potential to improve reproducibility of assessments. Maybe, just maybe it will get good enough to help mitigate the problem of less experienced operators using ultrasound.

multimodality fusion for interventional procedures - already, you can do a TEE (a kind of heart ultrasound) and fluoroscopy (video version of X-ray) and fuse the two images in real time to guide cardiac interventions. Maybe this will extend into other areas: e.g. guiding vascular access by fusing accelerometer / gyro / magnetic positioning / video camera data with ultrasound

virtual reality or augmented reality applications to accelerate the acquisition of ultrasound skills. There are already simulators but they're expensive; as they become cheaper and more doctors have access I'm hopeful we can improve the learning curve for image acquisition a bit!

This kind of description can be made of any hardware piece. We came from a whole room, slow computer to an iPhone that can make billions of operations per second. I see the previous post as complaining about this not happening on the industry.

Of course making an iPhone (or a OnePlus phone if you want to get into low-scale) is not easy, but the technology has advanced and standardized enough to be considered "cheap" for what they offer, and really cheap compared with 10-20 years ago.

Why hasn't that happened with ultrasounds? Certainly most of the components have been around for a while and the process of making a "simple one" (in the way the average smartphone is simple ) should be a solved problem.

I'm a hardware engineer and might be able to explain a bit. Industrial electronics doesn't seem to move at the same pace as consumer electronics from the outside, but there often is incredible progress at the same pace and perhaps faster than the consumer segments. It is often hard to discern to the outsider, because they lack domain knowledge to recognize these advancements.

On top of this, in certain fields, costs appear to remain stable and even go up a bit over time. In these industries, there typically isn't much demand for lower specc'd (AKA outdated) hardware. Often these products last such a long time that the used old models serve as the low cost market. Apple even copies this model by keeping their older products around longer than other companies and selling them at a lower cost.

In addition, the development of many industrial electronic products is extremely expensive and the markets are small (think 100s to 1000s per year). The company typically has to charge a very high price to stay in business.

While it's easy to look at something and think "I can make that with an Arduino or Raspberry Pi," this is basically the hardware equivalent of telling people you can make Facebook in a weekend (which used to be a popular claim here on HN years ago).

For me its the same as pharma. Can you tell me if a government (ex India) would like to devote resources to make cheaper ultrassounds they wouldn't be able to? I only buy non-technical arguments, unless the bill of materials is on the same order as the price of the equipment.

With pharma I think the main "cost" involved is about the risk of investment. It takes billions of Dollars to potentially make billions of Dollars from a single product. More likely you invest hundreds of millions of Dollars with no return at all.

It takes a special kind of company, almost a bank, to stomach that kind of risk. And this extraordinary risk also demands extraordinary rewards.

Medical technology isn't really the same thing.

The assessment of pharma isn't true, and is evidenced by their high profit margins along with price difference between different markets - same exact thing is substantially cheaper in the EU than in the USA.

How do you pay R&D engineers, prototypes, production, sales, support, etc... with such a low quantity volumes if the price is on the same order as the BOM?

Actually, depending on your precise definition of "same order", I could argue it already is. And while the gross margin will seem high if you are only used to consumer stuff, this is an almost useless metric for low volumes, where the net margin do not necessarily follow.

There are also not a ton of different vendors, so even dreaming about mutualizing some R&D costs (and that will mostly not happen), you would not save a lot.

Once again, cheap portable machines (but not able to do a lot) already exists.

I came here to make exactly the same argument. Or cars, if we pick something that also needs certifying (from a purely manufacturing perspective). I get that most people would rather have a car, so more cars get made, so they're cheaper. (Athough roughly comparable, and there's different models. To me, it seems a car is more complicated than an ultra-sound system).

The author of the original article made a good point that there may be a market for cheaper, non-medical ultrasound. The author of this article totally ignores this. Of course he's going to say they ought to cost as much as they do.

> but for now take my word [...] seriously, you don't want to use these things without strong safety regulations.

Why? Instead of being a condescending asshat and lording his career achievements over us, this guy could have explained if and why it might be dangerous to build one yourself, again for non-medical use. Wouldn't a good article with great arguments be more convincing than a list of credentials?

(edit: I'm reasonably convinced that devices in hospitals probably should cost that much, but this article didn't change that significantly. some of the details about impedance matching were interesting)

Cars, iphones and laptops are sold in quantities that are magnitudes larger than ultrasounds. Even if every school bought one for students to experiment with, you'd still only have all schools and doctors in the world as potential market. On top of that, medical devices are supposed to work in comparatively harsh environments (strong disinfectants etc.) for a long long time. Iphone lifetimes are measured in years, not decades and don't you dare and try to get a spare part for a 10 year old macbook. All of that means that evolution is much slower in that market - more small steps rather than big disruptive changes.

I'd also challenge that cars are more complicated than ultrasounds. They do have more moving parts, but allowed tolerances are magnitudes larger than a few microns in all places.

... but the "magnitudes larger" that they are sold is also endogenous to the regulatory framework around them. Suppose you had to get a PhD in physics to be able to get a drivers license. All of a sudden we would see a lot fewer buying -- and therefore far fewer people selling -- cars since it is so expensive to actually be able to drive them.

With these ultrasounds, there is such a heavy regulatory framework at work -- from regulations impacting the device itself to regulations preventing hospitals from being built to regulations preventing hospitals from having as many of these as they want -- that they make the actual quantity demanded of these things artificially small. Your point about evolution of the technology also falls trap to this same fallacy: Again, if all of a sudden you are artificially making something much more expensive to produce, it should be no surprise to you that the refresh rate on the device would be smaller. Here you also have the added effect that since we rarely pay for our own medical care and instead rely on insurance, many of the incentives that would exist for companies to make cheaper, faster, better equipment also disappear. Lastly, I fully concede that it is quite possible that there is some basic, inherent quality of ultrasounds that make them more complicated than cars or any other pieces of tech. But that isn't important. The importance is realizing that the derivative of the state of these machines looks very different from other technology industries where competition and the free market are much more of a factor.

Ultrasound systems is probably the cheapest modality, there is quite a lot of competition in this market, there is a lot of innovations in this market, the machine are getting cheaper and more compact, and at least in the developed world there is no penury of ultrasound systems, the regulation are there to prevent somebody to build a shitty machine that for example burns you with and endoscopic probe (you would not like that), and the interpretation of ultrasound images requires to be highly trained (you won't even understand the basic physical features you have before your eyes if you are not trained, due to various artifacts that are intrinsical to the technology), which limit the potential for delivery machines to a significantly larger market, because all those machines would be of no use.

I do appreciate being called a "condescending asshat", I might get a t-shirt with that on it, thanks.

I though my credentials were one paragraph instead of many, but maybe I need to count again.

As for lording it over you with qualifications - I just needed to make it clear that I actually do have a huge amount of experience in this area, otherwise instead of being a "condescending asshat" people would be asking who the hell do I think I am commentating on this.

I make no apology for knowing what I'm talking about, there's too many articles written by people with no idea about the topic.

And don't take it personally, I've something of a reputation in ultrasound for being blunt.

A car is not necessarily more complicated than an ultrasound system.

Now the definition of "complicated" can be subject to debate, but you could be surprised if you compare the production prices of simple/high-end cars and simple/high-end ultrasound systems.

Really high volumes help a lot for all components. There are more and more components in ultrasound system that can be reused OTS from other markets, but even then, those larger markets are not necessarily larger than the cars market!

And it is not too dangerous to build one yourself for non-medical use, although it might be a little harder than you seem to think. But if you are reasonably skilled, I believe it is doable to design a toy system reasonably cheaply (but simply, do not expect to be able to use a raspberry pi GPIO and obtain something non-shitty). Go on if you want!

Indeed, but for the imaging industry there are only two potential clients: medical and welding. The hobby/educational/large masses market don't make the cut so to scale down the costs.

The IT industry price ranges were also in the millions of dollars before people had a need to play Angry Birds on a device in their pocket

* Several IC makers are selling integrated devices (TI, Analog, Maxim), for example at TI: LM96530 (Beamformer), LM96511 (VGA/LNA) and LM96570 (TR Switch). Those are eight channels ICs, they cost $200 together. There are ICs for 16 or even 64 channels.

* Another claim is the need for a huge number of piezos, this probably a view from a remote past: With adequate coding and enough channels to enable beamforming, there is no meaning in having this extravagant number (200) of transducers IMO.

The basics of imaging require a certain number of elements. The acoustic window must be a certain size for the application, the elements must be smaller than a wavelength to avoid grating lobes (0.5 wavelength for perfect phased arrays in that regard). Divide one into the other, and you get a number of elements that's usually between 100 and 200.

On what basis do you make your statement that this is too many elements? IMO implies opinion, do you have any facts or physics to back up your statement?

Laws of physics do not change with time.

>> do you have any facts or physics to back up your statement?

I do not think that beamforming needs more than a few emitting sources neither a Nobel prize. Check no further than your Wi-Fi router's antennas.

The technology you are describing is entirely different and older, as in your description there is no beamforming.

In the technology you describe, there is a requirement for two emitters/receivers to be separated by less than a wavelength, however this strong requirement does not exist for beamforming.

What makes beamforming useful is modulating and coding the beam. Another thing important is the SNR, as it is the addition of the waves that creates "beams".

When I checked Google patents I found beamforming patents in ultrasound imaging since 1986, and super-resolution (pionnered in astronomy and microscopy) in ultrasound imaging since 2005 (US 20050160817).

e.g. the LM96530 is lifebuy, so it's basically discontinued. LM96511 & LM96570: not recommended for new design. In other words, those ICs are basically obsolete.

Thanks for pointing out right to the important thing: Those ICs are not new, they are on the market since some years.

And have probably been used in some cheap systems?

I don't know if the $200 quoted by the OP for all ICs is bulk pricing when they were new or $200 now when they are limited and special parts. But it's moot anyway, I doubt the ICs are the major price point.

The fallacy this author makes in his response is unfortunately very symptomatic of our society's poor grasp of fundamental economic principles. Worth noting that despite failing to see some of the larger forces at work that the previous post mentioned the author nevertheless acts condescendingly towards that other post, which is also very similar to how society-at-large operates.

The one factor the author completely fails to engage in is the fact that the state-of-the-art of ultrasound production and the resources devoted to its development is entirely endogenous to the regulatory and market structure around it. He spends a great deal of time justifying the price based on the technical challenges involved in building the device, but this completely misses the point. The market doesn't reward innovators or companies because their product is "complex."

The matter-of-fact is that we have crazy regulations in the medical space that sharply distort both the demand and supply of these machines. On the demand side, there's bat-shit crazy things like the fact that in order to open up a new hospital, in certain regions the existing hospitals in the area have to all agree that they are okay with that. Imagine what the technology landscape would look like if every time Apple wanted to open a store it would have to seek approval of the Best Buys that had already been there.

We also rarely pay directly for our own medical treatments. The fake prices we see in medicine (I was once hospitalized for < 1 day and the "bill" came out to > $40k; a juice-box in an itemized hospital list could cost $12, etc.) are a great indication of the lack of competitiveness in that space. The truth is these fake prices reveal the fact that no one actually pays them, and instead are like that so insurance companies can negotiate individually with treatment providers. Now, given all of this, who could possibly enter this space and try to sell you on the idea that they could make an ultrasound that is 10% cheaper?

10% cheaper, that is, on top of an already highly-inflated price. Elsewhere in medicine, the INCREDIBLY high cost of FDA drug approval is extremely well documented, costing in the billions of dollars to bring a new drug to market. I hope it wouldn't shock the author of the post to learn that, with that incredibly high cost to play ball, the default scenario is for young medical startups to quickly sell to pharmaceutical giants, as that is really the only way to bring drugs to market. At a smaller scale, this too happens in the ultrasound arena, thus also making their price artificially high.

Speaking more broadly, the author's post is symptomatic of a view of much of our society which ends up treating prices as exogenous things. "College is expensive," "medicine is expensive." are things you hear all the time, and said with the intent that this reveals some fundamental truth about these things. That's garbage. College is expensive simply and only because colleges have been charging that much and people have been paying for it. Full-stop. In fact, the "free college" would be wise to understand that much of the increase in the price tag can be explained by the artificially low rates that you can borrow to attend them in the first place. I lived overseas for many years, and despite having Harvard Medical School-trained doctors and frequenting world class hospitals there, the actual, full cost of those treatments -- which I paid individually -- were a fraction of what they would have cost me in the U.S.

I definitely get this argument that regulations decreases competition, but they are there for protecting the consumer. I don't believe they were created to skew the marketplace, but they have indeed done this. It's a tough question, because self-policing doesn't work, we need organizations designed to protect the consumer.

The recent fight between CA, SF and Uber around the "self-driving car" tests is interesting to me personally, because I ride my bike in San Francisco almost every day, and sometimes with my kids. I do believe that self-driving or driver assisted cars will be safer than people alone, but I also want to know that there have been some amount of testing requirements met so that I know my family and I are safe.

So I ask this question, if your premise is that regulations are overly burdensome, and there is evidence to support this, what do we replace it with to get the same or better oversight of industries?

As cliché as my answer might be, I really believe in it: competition. There is no force quite as good as keeping companies from shafting consumers quite like competition.

Now, I'm also not knocking safety requirements. I'm fully aware that some of those structures exist for a very good reason -- I just feel like we have gone way overboard in virtually every industry. For a great piece discussing the medical industry specific, I highly recommend this essay: https://faculty.chicagobooth.edu/john.cochrane/research/pape...

>On the demand side, there's bat-shit crazy things like the fact that in order to open up a new hospital, in certain regions the existing hospitals in the area have to all agree that they are okay with that.

I don't believe this is necessarily batshit crazy because hospitals in close proximity will coordinate to manage patient flow. There is also likely disaster coordination but I've not seen that directly.

"Hostile takeovers" by hospital conglomerates (of which are growing bigger these days) would also be very socially upsetting if their entrance causes existing hospitals to shut down. Hospitals are not something you want competitive churn in.

What is batshit crazy is blocking new hospitals while maintaining high patient to staff ratios and having capacity issues (e.g. getting beds to patients).

>> coordinate to manage patient flow

Right there. That's why the costs are so extreme.

Where is it written that someone must 'coordinate to manage patient flow?' Show me what fundamental principle of this nation mandates that some body of colluding apparatchiks are supposed to 'coordinate to manage patient flow.' What great benefit is achieved by subjecting every evolution of the medical system to a horde of bureaucrats?

The entire medical industry is rife with this mentality; that nothing may exist without the blessing of a dozen regulatory agencies and another dozen industry trade groups, all actively colluding to prevent any market forces interfering with their fiefdoms and livelihoods.

>> Hospitals are not something you want competitive churn in.

Why? Where is that written? What makes you think competition would be bad?

You're going to claim something like "churn would make medicine dangerous and put lives at risk." Maybe. That's your guesswork. The last major illness I had -- the only one more exotic than a flu I've ever had in my life -- was C. diff, contracted in a US hospital while visiting a patient. Don't tell me the unbelievably huge costs of our medical system are some surety against risk.

The US medical system is the biggest bubble in the history of our species. At some point the forces of nature are going to pop it. That's not a right wing view or a left wing view. It's just physics. These costs cannot continue to compound unless you're willing to employ gulags.

I'm betting that in the aftermath a full featured ultrasound machine will cost maybe $15k and the biggest measurable effect of that (if anyone is bothering to measure at that point) will be that there are more of them and more people will have access to them. And yes, I'm fully willing to risk whatever parade of horribles you can imagine. I'm also willing to make you risk them as well, and the pressure being created by spiraling costs means that have eventually I and the many, many people that also share my view, will have the power to do exactly that.

The author mostly said that: this kind of equipment is intrinsically quite expensive, because lots of various tech are intrinsically high-end. Now there is also the question of regulation. From my experience, the major part of the cost of a system does NOT come from there, even if regulation does not have a trivial cost. The major part of the cost comes from the BOM, from R&D, and from sales. And this is a sector where there are lots of innovation, despite all of that.

Pretty good summary of what I said, thanks.

Really eye-opening to read in order.

Original blog post author here. Thanks to everyone for their comments, I've tried to answer as much of the issues raised as I can in a new blog post, here.


TL;DR summary - ultrasound engineers are not stupid, are adding capabilities as they can, and driving costs down, but demands keep rising as new applications are found, and there is not yet the "killer app" demand for ultrasound that will drive smartphone sized economies of scale to lower prices massively. Regulation is not a huge cost driver (and you seriously do not want no regulation), and there is no cartel action in ultrasound conspiring to keep prices high, it's actually an incredibly competitive industry.

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