2025: 20% doctor included?
an exercise in technology
speculation & musings
vinod khosla
vk@khoslaventures.com
@vkhosla
10% to 20% of cases:
delayed, missed, and incorrect diagnosis
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graber, et al., jama
40,000+ patients in u.s. icus
may die with a misdiagnosis annually
3
winters, et al., bmj quality & safety
in many records of patients with a high-risk
diagnosis, high-information clinical findings
were present before the diagnosis was
established
4
feldman, et al., jamia
50% of MDs are below-average
5
math
human doctors
cognitive limitations
cognitive biases
6
a study of one hundred cases of diagnostic
error involving internists found…
7
…system-related factors contributed to the
diagnostic error in 65% of the cases and
cognitive factors in 74%...
8
…premature closure was
the single most common cause
9
the value of second opinions
cleveland clinic doctors’ review of initial diagnosis
disagree with initial diagnosis
11%
find need for further testing
15%
recommend major changes to treatment
plan
18%
recommend moderate changes to
treatment plan
26%
recommend minor changes to treatment
plan
patients switching doctors after receiving
second opinion
10
22%
5%
http://www.businessinsurance.com/article/20111204/NEWS05/312049987?tags=|74|305|339|342
for most study designs and settings,
it is more likely for a research claim
to be false than true
11
john ioannidis
wide ranges of uncertainty
fifty-eight experts’ estimates of the chance of an
outcome of an important procedure
0% 0.2% 0.5% 1% 1% 1% 1.5% 1.5% 2% 3%
3% 4% 5% 5% 5% 5% 5% 5% 5% 6% 6%
6% 8% 10% 10% 10% 10% 13% 13% 15%
15% 18% 20% 20% 20% 25% 25% 25% 30%
30% 40% 50% 50% 50% 62% 70% 73% 75%
75% 75% 75% 80% 80% 80% 80% 80% 80%
100%
12
eddy, et al., jama
wide ranges of uncertainty
seventeen experts’ estimates of
the effect of screening on colon cancer deaths
0%
25%
50%
75%
100%
proportion of colon cancer deaths prevented
= one expert’s response
13
eddy, et al., jama
surgeons were given detailed diagnoses
& asked if patients should get surgery …
half said yes … the other half said no …
when asked again two years later,
40% of the docs gave a different answer
14
eddy, et al., jama
there is good reason
to challenge the assumption
that every individual practitioner's decision
is necessarily correct
15
eddy, et al., jama
would
a hospital cure you
in half the time…
…if it meant
cutting their business in half?
16
the folly of experts: tetlock study
hundreds of “experts” …
28,000+ forecasts over 20+ years
results: “experts” are poorer
forecasters than
dart-throwing monkeys
17
http://www.newyorker.com/archive/2005/12/05/051205crbo_books1
entrepreneurs will ask
the naïve questions that uncover
hidden assumptions…
…and move us to
the grey zone of “speculations”
18
in the future,
patients will have the data & analysis to
become the CEO of your own health
19
peter diamandis
80% of what MDs do can be replaced
(with better care than the average MD)…
…but not every MD function will be
replaced
20
lifecom CHAMP
I …distributed care with medical assistants
were 91% accurate
without labs, imaging, or exams
II …“safe triage” with 75% physician bypass
rate for acute care encounters
21
isabel II
matched expert diagnoses
95% of the time
22
machines are better at integrative medicine…
…across “all symptoms”, demeanor, patient history,
phone activity, 1000s of data points, genomics,
population management guidelines, …
…and machines won’t have to win
every red state and blue state…
…they’ll just be better overall
23
the “human” element of care can be
provided by the most “humane” humans
(and MDs can be humane)
24
the transition will start with
“toddler MDs” and digital first-aid kits
25
dr. algorithm
v0
26
keep people out of the doctor’s office…
…with point innovations in cardiology,
dermatology, optometry, psychiatry,
internal medicine, …
27
healthcare service stations
&
digital first aid kits
28
...and your innovation here (call us)
29
innocuous point innovations…
…will become a wave…
…and grow into a tsunami
30
dr. algorithm
v0
v1 – 2015
v2 – 2017
v3 – 2019
v4 – 2021
v5 – 2023
v6 – 2025
…
31
we’ll start with clumsy point innovations
like alivecor, cellscope, adamant, ginger.io,
neurotrek, consumer physics, jawbone,
misfit, …
…“insighted” by Ayasdi…
…leading us to discover things we never
knew were right in front of us
32
the best MDs will train systems
over 10 years…
…systems will symbiotically provide
“bionic assist” and “AMPLIFY” MDs
33
dr. house+++ will be
the trainer for dr. algorithm
…no manners required!
…but manners learned!
34
findings thanks to data
using statins for in-hospital stroke patients
reduced the death rate by 40%!
35
kaiser permanente
the practice of medicine
the science of medicine
36
there aren’t enough rural doctors in india
and few have access to jama journals, mris,
…
…the world of medicine
is under-resourced globally
37
the shift to “computerization” has already
happened in other areas…
…airline pilots, stock trading, car driving
38
I will be wrong on the specifics but
directionally right
39
20% doctor included?
vinod khosla
vk@khoslaventures.com
@vkhosla
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