Paul Alan Wetter, MD - Medical apps: Ideas for endometriosis and how they will change your practice
Scientific Symposium
Advancing the Science and Surgery of Endometriosis
Monday and Tuesday, April 19, 2016
The Union Club, New York
This is my disclosure. I am Chairman of the Society of Laproendoscopic Surgeons and one of the reasons I am here is that several years ago we realized that endometriosis is a multi-specialty disease. We needed to train the next generation of endometriosis surgeons. Along with Farr Nazhat and a committee of experts from around the country and around the world we established the first multi-specialty endometriosis fellowships, one at Stanford, one here in New York, one in Atlanta and another in Orlando. We are now in our second year of those and the idea is to expose fellows to a year of intensive training in minimally invasive surgery with expertise in not only gynecology but in general surgery and in endo-urology. I am pleased to report that those programs are going well and will soon be extended to other locations.
SLS also has another important fellowship and that is in simulation. This year our simulation fellowship was at the University of Minnesota. It is now going to be at the University of Washington in Seattle with Rob Sweet. The idea behind that is related to a lot of things that you saw this morning those things related to pilots learning by simulation and that sort of thing. One of the comments was made that we do not quite have the simulation yet that duplicates what you would see but in fact we do. One of the first was presented last year at MIS week, which is the annual meeting of SOS, many of you saw the bleeding vena cava simulator. It was so realistic that two of the residents who were being checked out in the simulator got dizzy and almost passed out. When the blood started to flow it looked as realistic as what you see there.
That is my disclosure. My other disclosure is I love Apple. Samsung, they make great TVs, they have nice displays and I love Google, they have great search facilities but I really love Apple. Some of my talk may be geared more towards Apple but I think that is because Apple has shown over and over again that it has the ability to advance computer technology and interface with people. That is a little bit about what I am going to talk about today.
We live on this little marble that is going through space. Today we are here in New York City. I live in Miami. A few years ago I would be giving a talk like this in one part of the country in one part of the world and people may never hear about it or understand what is going on anywhere else. It is very different today. Today, through the internet, we can be speaking in New York City and people in Beijing can hear this or see this and know what is going on. Information is travelling. Our little blue marble that is travelling through space there is a lot going on, a lot of networking and communication around the world that is bringing knowledge and information. This is just part of what is happening with the connection of technology.
These are words that did not exist when I was born. The world is changing very fast, even within the past year or so there were hundreds of new words within technology that are changing the way we __________. Most of those _____ we are dealing with things like endometriosis _________ today or with surgical techniques.____. What we are losing track of is that things are always changing. We are in a little time capsule that is moving along and what we have today is not important. It is where we are going that is important.
One of those things is Nano Technology. We are now able to make things that are very, very tiny. Another thing is related to this, eighteen months. Who here knows the significance of eighteen months? There are some young smarties in the back here. Anybody here raise your hand, eighteen months, Moore’s law. Well maybe, or maybe it is the gestation of an elephant. Actually eighteen months is the gestation period of an orca, not an elephant. What is your name? Jason, okay, Jason you are right. This is Gordon Moore who is the father of Moore’s Law. Moore’s Law says that computing power will double every eighteen to twenty four months. And computing power has in fact done this over several decades now. It is really moving along very, very quickly.
Before I went to medical school I worked in a bank for seven years. This is our bank in the late 1960s. They used before this computer was put in, it was a room this size with all these IBM mainframe computers, those little discs…do you want to participate – no I don’t, why would I want to do that…(Audience - that’s what happens when you mix Apple and Microsoft). That Microsoft I’m telling you. (Audience – you are in computer purgatory.) I’m telling you but here is the beauty, I can recover quickly. It was a room this size and each of these discs held a few megabytes but before these discs the tellers in the bank – there were two things that went on in banks, this was before the banks were too big to fail, these were regular savings and loan banks – they took savings from people in the community and then they loaned it to other people in the community to build houses. But every day the tellers if they were a penny off they did this by hand on ledgers. If you withdrew $25, they did not have ATMs, you went into the bank and said, “I need $50” they had to write on a little card, it was your ledger card, it was like medical records before digital. You had to write it in on a card and add it up. If they were a penny off they had to stay all night. These computers were so smart that they could add and subtract all those cards. That is all they did. But it was a big thing.
Here is one of the ladies that worked there and the disc she has is a magnetic tape that held about 28 megabytes. The computer itself stored information on big steel drums. Excuse this slide but look at this slope that is going up. This is where we were when we had the IBM mainframe computers. They were as intelligent as a nematode or a bacterium. This is where we were when the first Mac computer came out. Remember those little Mac computers that looked like ET? This is where we are today. This is where we are going to be within two years, this is where we are going to be within four years, actually, no, we are going to be more like this.
Your mobile phone, the phone in your pocket – how many people here have the iPhone 6? Three billion with a B, you have three billion transistors in an iPhone 6. It is amazing computing power. Our mobile phones now have more computing power than all of NASA had when they launched the man to the moon. For those of you interested in operating a lunar lander here is the operator’s manual. This is the Houston control center when they launched the man to the moon. All these engineers and all these computer terminals if you added up all the computing power in there plus the power of the rocket plus the power of the lunar lander, plus the power of any radio control stuff on Neil Armstrong it is a small fraction of what you have in your pocket today.
In fact, these super computers in our pocket are more powerful than the computers that were used to solve the human genome project. It is amazing computer power and it is that and the Nano Technology that are causing some amazing things to happen that are going to affect us all. They are about to collide.
Nano technology and computing power it is an amazing thing that is going to happen that is going to change everything and the change is not coming from the inside of medicine. Most of us within medicine are unaware that this tsunami is about to hit. Just like the cab companies, how many people took cabs today – how many took cabs, Yellow Cab, Yellow cabs? How many took Uber? Okay. Those Yellow cabs lined up down the street two or three years ago they were worried about the cost of cars and the cost of tires. Today they are worried about the cost of cabs and the cost of tires and they have no idea what is happening. Uber is taking over because it involves using technology, aerospace technology, GPS systems and systems that just did not exist and super computers in our pockets.
Let us talk about app developers. I am an app developer for Apple and I thought that was a pretty big deal. We developed some of the first medical textbooks and journals. I go to the Apple developers conferences and I was there in 2014 when Tim Cook, the president of Apple Computer got up on the stage and said he would like to welcome the nine million app developers, up 47 percent from the year before. Today that number is 15 million. So there are 15 million people worldwide, and growing, who are working and developing apps to make this super computer do super things. Out of that a percentage are working on medical things. There is the group from Flutter who is here today. You guys are in the room? Back of the room. But there are thousands and thousands of people. I have done some work, I originally worked on the original design for the Endo Shear and some of the instruments back in the 1980s that Harry and I used. All the biomedical engineers in the world are a pinhead and all the app developers working on medical apps would fill the Empire State Building.
These are medical apps and science apps.
What is the problem? What is the problem with medicine? What is the problem with Yellow Cabs? Why is Uber so much better? Do we really have problems in medicine that need other things to come in and disrupt us? Well, according to JAMA ten to 20 percent of the cases are delayed or have an incorrect diagnosis. According to the Institute of Medicine nearly half of American adults have difficulty understanding and acting upon health information. Human doctors have cognitive limitations and cognitive biases.
Here is a study from the Cleveland Clinic that was published. It showed that – this is people who had an initial diagnosis and a second opinion – now these are second opinions with experts. Eleven percent of the second opinions disagreed with the initial diagnosis. Fifteen percent found the need for further testing. Eighteen percent recommended a major change in the treatment plan. Twenty-six percent recommended moderate changes to the treatment plan and 22 percent minor changes. The good news for us only five percent of the patients switched doctors after all of this. Is medicine a science or an art? What part of medicine is a science? If we are a science why are we not all giving the same diagnosis? Why are we not all coming up with the same treatment plan? That is a problem.
This is my favorite - math. The other 50 percent are not in this room, do not worry. Here is another scare thing. These are 58 experts, so 58 experts in breast surgery were asked to estimate the chance of a spontaneous rupture of a silicone breast implant. And here are the answers. They all gave basically different answers – all across the board. Again, are we a science or an art? Is the art of science the ability to communicate with patients? That is good. But the art of science should not be guessing about what an outcome or result or understanding of what happens.
Here is what is happening. This is the American Canyon, Napa Valley in California. About two years ago there was an earthquake do you guys remember seeing that in the news? There was an earthquake there. So an interesting thing was happening during that time. How many people wear a Fitbit or Jawbone products? A lot of you, okay. There were about 300 people in the region who were wearing things like that, sensors on their body and as you know some people wear them to – medical people do not know this – some people wear them to see how much sleep you are getting and how soundly you sleep. But you guys wear them to see how far you are walking every day. There were 300 people in the region and at 3:00 in the morning at the server back in Jawbone Headquarters they saw this spike. They knew before all those people knew, or anybody else knew, that something had happened to wake all those people up simultaneously.
Imagine, imagine – how many people have Apple watches? No Apple watches? One Apple watch, okay. Within a couple of years we are all going to be wearing some sort of sensors. This Nano technology is creating thousands of kinds of little tiny sensors that are very inexpensive that you can wear to measure pulse, oximetry, electrical conduction, body temperature and things like that. So imagine within a year or two we are all wearing some sensor and in Chicago the CDC is noticing on the servers that there is a little, at that table somebody had an unusual fever. Then two hours later they noticed that the next person over there has another unusual fever. I am pretty convinced with all that. By the way, how many times a day do you check your post-operative patients’ temperature when they are in the hospital? Just blurt it out. Three times a day. When you send them home? None. Post-op infections happen sometimes. Of course. How do you know about them? The patient calls. And says, “I have a high fever for four days and I have tried everything else and my stomach hurts”. Within a year or two all these patients are going to have sensors. They are going to go home. Before that patient gets any symptoms they are going to get a notice on their phone. I have called Dr. Seckin’s office and made you an appointment for 2:00 you may have an infection starting but we can nip it in the bud. No problem, come in and we will take care of it.
The people in Chicago who have a fever, I am pretty convinced with that much data these are sensors that are going to be checking pulse and temperature every second, 24 hours a day. With that much big data I am pretty convinced that Ebola will have a different fever curve than the common cold, which will have a different fever curve than influenza. And the CDC will know by the time the second person gets an infection where they are and what is going on. Just like the Uber driver knows where you are.
We are entering this brave new world of technology and it is happening fast. It is happening from the outside of medicine. It is going to disrupt medicine the same way that Uber has disrupted the cab companies and the same way that Apple has disrupted music and the same way that Amazon with books and I could go on and on and on.
Here are some things. This is an infrared sensor that works with your phone so you can see hot spots in the body. This is everything you would find in an ICU ten years ago you can now do on your phone. This is a guy in a little village in Africa getting a glaucoma test. A little shout out to Samsung they do some good things. This is a spectrometer it can tell you that – what are you having there, you having the tuna? It will tell exactly what is in your food and all the different chemical components right to you phone, a Selloscope. So then there are some apps that are starting. One of them is Safestart, which is a surgical app that does informed consent. It has pictures of the patient, the patient identifies that their right knee is sore and they circle it. When they get to the operating room everybody has a copy of that so the idea here is to eliminate wrong side surgery which is still a problem even with time outs and checklist. By the way, we use the airplane and the analogy of the airlines for medicine. We have all started to do, work a lot with OR already and things like that and we have started to do checklists, WHO checklists, time outs and things like that. The big difference in the airplanes today when Sully Sullenberger landed his jet on the Hudson – computers. They have computer sensors for everything. Those things that we are starting to implement helped a lot but they were not the final thing that really made airlines so safe. The final thing that made airlines so safe is computer technology and the ability to track things and to control the plane. You all know about Google and Tesla and the automated cars. The number one thing they say is they are safe. There is no human error, theoretically they will be safe. We have things like this but the ability to now implement some of these things is amazing.
Here is another one where you can take pictures of your patient and communicate things to the outside world and then it sort of disappears. Sort of like is that Snapchat or which one of those is it where you, yeah it was before Snapchat.
Here is the Apple watch that we spoke about a little bit but the sensors every iteration of these are going to have more and more sensors telling you more and more things. There are a lot of folks around like the Flutter group who are trying to collect data now with endometriosis through collecting data. So this is the research kit that Apple developed. Now, I have the iPhone 5 I have ordered my new iPhone, you see I just like the small phone. I should get that by the time I get home. But those of you – who has the 6s again? Okay you guys all have the M7 chip in there. The M7 chip tracks your health data. It is an entire processor with billions of little things on it that track that. So there have been a lot of institutions now around the country that have started this but this is something that is accessible to all of us. There could be things that work like Flutter is doing and things that work with a research kit to develop apps that go on the phone that your endometriosis patients could have and you can track and collect data from. The advantage of this is instead of you getting 20 patients in your practice this will attract thousands and hundreds of thousands of people around the world and give you tremendous amounts of data. Very quickly that will help solve some problems.
This is a little more of the kinds of things they can do. There are now apps to diagnose, to understand the progress of Parkinson’s. Somebody will take a pill for Parkinson’s and then they were supposed to come back in six weeks and let the doctor know how they are doing. Now they have an app where they move their finger on the thing or they do some little thing on the phone and it can tell the differences. It can tell how effective the medicine and how effective it is working. Image that with treatments for endometriosis and how those things might work.
It is a brave new world. We do not know exactly where we are going. We do not know exactly what the apps are going to be but there are a lot of things and it is going to change everything in a big way. I encourage all of you to those of you who are not computer nerds to hire the kid that is tinkering in his garage next door and put him or her on your team. Get somebody involved in any of these projects that you are doing because this is the thing that is going to happen. Do not be that line of Yellow Cabs sitting there on the corner because this is happening. The AMA hardly knows about it. ACOG hardly knows about it but it is going to change all of our practices. It is going to change medicine. A lot of patients that you see are going to be treating themselves at home with apps. Just like Uber, it is hard for us to believe but doing a better job of some of these things.
