How will the phenotype of a doctor change in a new health landscape dominated by technology?
The Creative Destruction of Medicine sets out to examine the changing landscape as the digital revolution penetrates hospitals across the globe. As junior doctors we strive to provide the very best care for our patients, but all too often we find ourselves going to battle with inefficient systems and out-dated technologies. Most would agree that the health sector stands to gain enormously from the digital revolution, but for those on the ground the end-game remains elusive.
Eric Topol is a leading voice on the digital transformation of healthcare. He is a cardiologist by training who has been ranked as one of the world’s top ten researchers. Formerly known for his role in questioning the cardiovascular safety of rofecoxib during the Voixx controversy, he is now the editor-in-chief of Medscape and director of the Scripps Translational Science Institute in California.
Topol begins with the provocative argument that medicine has become imprecise and wasteful as a result of our blind faith in randomised controlled trials. He believes that we apply research indiscriminately to individuals without trying to predict those who stand a gain a clinical benefit, the so-called ‘responders’. I was initially sceptical of his stab at the heart of evidence-based medicine. However, when confronted with data that as few as one in sixty people benefit from taking a statin in primary prevention, it does make you wonder whether shifting towards personalised medicine will sharpen our aim. While sequencing the human genome has not yet allowed us to cure genetic diseases, it can predict individuals with drug sensitivities. Perhaps using these tools will allow us to predict those who will benefit before reaching for our prescription pad, particularly given the onslaught of expensive monoclonals.
Will shifting towards personalised medicine sharpen our aim?
Computational power continues to increase exponentially in accordance with Moore’s law. The result has been the development of wireless remote sensors which integrate with smartphones and other wearable devices. Topol believes that sensors will improve the management of common medical conditions in real time. By transmitting this data to physicians, patients will no longer wait for an appointment to optimise management of their BP or BSL. Topol recalls his excitement when he received an email from a patient with an ECG monitor in his smartphone which read, “I’m in atrial fibrillation, what do I do now?” Health data stands to empower patients to become more involved in their own care.
Topol believes that these portable technologies will also change clinicians’ practice of medicine. He points to the availability of pocket-sized high-resolution ultrasounds. He believes these will become part of the physical exam and usurp the iconic, but rather primitive, stethoscope. I can imagine a world where doctors roam the wards with ultrasound probes attached to their smartphones ready to tackle difficult intravenous access, problematic ejection fractions or even troublesome gallstones. However, at thousands of dollars per ultrasound probe they remain cost prohibitive for most clinicians to integrate into their practice.
Technology will radically change how patients interact with their doctors according to Topol. In America, it takes two weeks to get an appointment with a primary care doctor, together with an average wait time of 60 minutes. But now, with the advent of remote monitoring and telemedicine, many of these consultations can occur remotely. And although GP appointments are more readily available in Australia, at least in the urban setting, this has not stopped the proliferation of virtual medical clinics offering to write medical certificates and make specialist referrals. The uberification of medical consultations has seen the proliferation of telemedicine and after-hours doctor services. These might just replace many traditional medical consultations. However, Australian patients continue to face hefty out-of-pocket fees for many of these services due to current Medicare billing regulations. Reform will be needed in order to compensate medical practitioners who provide care at a distance.
Next, Topol asks "who should own the masses of patient data from sensors, genomic sequencing and laboratory tests?"" And what more logical answer than the patients themselves? Topol believes that the democratisation of medicine means that patients need to have ownership of their data. He is quick to counter paternalistic argument that medical data incites anxiety, quoting studies demonstrating that this is not the case. I agree that it is unnecessarily difficult for informed patients to access their laboratory tests and medical records. However, I wonder whether it is easier to argue for patient ownership of data in the US, where patients pay through health insurers, as opposed to Australia when tests are publically funded.
Topol also champions the development of transparent medical records. He references an initiative devised by Harvard graduates that allows patients access to their medical records requiring them to countersign alongside clinicians to verify their accuracy. They envisage a future where patients will be contributing to their own medical records! This seems to be a controversial concept when I pitch it to my colleagues. However, there is evidence that open notes may improve patient satisfaction and benefit the doctor-patient relationship. Perhaps it also serves as a reminder of patient’s values when they diverge from those of the treating doctor.
You might wonder, what is the future of the hospital in this digital revolution? Topol believes that the hospital admissions in the future will be limited those undergoing surgical procedures or requiring intensive care. The majority of patients will be treated in the ambulatory setting with monitoring of vital signs using wireless sensors, point-of-care blood tests and daily consultation with remote clinicians. Many health systems are already making the shift towards providing a greater proportion of care in the outpatient setting. This is an attractive strategy to better deal with the epidemic of chronic disease whilst containing costs, creating efficiency and preventing the iatrogenic harms caused by the hospital system.
Topol concludes that the phenotype of a doctor will need to evolve for us to thrive in this newfound health landscape. This has implications for clinicians, educators and administrators alike. Topol has many ideas on how the digital revolution might change healthcare. Only time will tell which direction the industry will take. Either way, in the future of health the digital revolution will take centre stage. For those seeking an entrée to the revolution, this is the book for you. With countless opportunities for innovation, there’s never been a more exciting time to be a disruptive influence in health.