The catchphrases for describing what’s happening in the practice of medicine are cute, and also informative and helpful in change management.
Dr. Eric Topol, a practicing cardiologist and professor of genomics at the Scripps Research Institute, has written a book calling for consumers to demand innovation and the democratization of medical care. Tying the explosion of technology allowing consumers to access information and monitor their health to the affordability and ease of sequencing individual genomes, he argues that population health and the practice of medicine will be “creatively destroyed” and an entirely new individualized form of medical care will emerge.
A move to value
Physicians are being buffeted by multiple pressures and incentives. Most changes in payment for healthcare are moving to “value.” A great deal of emphasis is placed on mass screening, and mass prescription medicine. Doctors get paid on the basis of how many eligible patients they enroll in cancer screening tests. We also get paid on the basis of achieving certain numeric goals, such as cholesterol levels and blood pressure.
All of this is swept up in the catchphrase “population medicine.” My regular readers will recognize that I am a strong advocate of these changes in payment to incentivize focusing on “the right things,” such as reducing readmissions and stopping wasteful testing and treatments. Dr. Topol argues that medical practice is undergoing a shift that will make these kinds of mass goals not only bad medicine, but wasteful spending as well.
I don’t believe this means the shift to population medicine is a bad thing. In fact, I think his argument and the current research allow us to think about taking care of a population of people in an entirely new way, and that is his point. However, shifting to the creative destruction that technology and genomics allow will need to overcome decades of behavior and expectations that both physicians and patients share. Dr. Topol argues that the medical profession is resisting change that is for the betterment of care, even rigidly resisting change.
The future of medicine
Where medicine is going is customized individual treatments based on our individual genetic makeup. Some of the most dramatic advances in this approach exist in cancer treatment. Right now the Massachusetts General Hospital Cancer Center, with which Cooley Dickinson Hospital collaborates, offers lung cancer patients individualized treatment based on the genetic makeup of their tumor. Depending on the drug regimen, Cooley Dickinson patients whose tumors are tested this way can sometimes be treated here.
What all this means to the practice of medicine, he argues, is ceasing the mass screening of the entire population in favor of “it’s the mutation, stupid” and doing genetic testing instead. The same with mass treatment guidelines — not everyone needs their LDL cholesterol lowered to below 100. In fact the literature on these mass treatments point out that the “number needed to treat” to save one life is 1 in 100 for cholesterol treatment in those without heart disease. Dr Topol suggests current science is allowing us to figure out who that one person is and treat the one, not the 100.
Consumers have a say
All of this also points out that the consumer makes the decisions and doctors may get squeezed out. This video of a 16-year-old with diabetes is funny but prescient. When his doctor told him that he could choose insulin dosages based on either his pre-meal blood sugar or his expected carbohydrate intake, he replied "that's stupid, I need an algorithm that takes into account both variables," and he went home and wrote one.
The practice of medicine will be very, very different in the near future. I do not think the changes will be incremental, but agree that we will undergo both disruptive innovation and creative destruction. Only by creating a vision for ourselves of what we want it to look like, will we successfully get there as individual practitioners and together as part of integrated systems.
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