Tuesday, November 18, 2014

Who Ya Gonna Call

Imagine, if you will, a health care system without doctors.

On first blush that concept doesn't make sense: what would a health care system be without doctors?  But I would argue that the notion is not all that far-fetched, and, even more, that we need to be open to ideas like that if we really want to change our health system.

Let's start with the basic assumption that, within a few years, we'll be able to track our health at virtually a molecular level, in real-time or close to it.  That's one of the goals of Google X's Life Sciences team, using something they call nanodiagnostics.  They envision a swarm of nanoparticles swimming around in your body, detecting diseases in their earliest stages, and connected to wearable devices so we can act on the information they glean.  Instead of waiting for diseases to manifest, we'd be able to catch them in their formative stage and head them off.

It's not just Google that sees this future; researchers elsewhere, such as at Northwestern and Vanderbilt, also see exciting opportunities in nanoparticles.  The Northwestern research, for example, helps identify circulating cancer cells faster and more easily.

Just think: we wouldn't need a physician to give us their best guess at a diagnosis; we'd actually know exactly what was wrong.

Well, even if we could replace physicians for diagnoses, we'd still need them to treat us, right?  Not so fast.  Take another hot field: the microbiome.  We're finding out that our bodies have a lot more bacteria than "our own" cells, and that what is going on with those bacteria has important implications for our health.  Imbalances in them have been linked to a number of common maladies, including allergies and other auto-immune disorders, cancer, and obesity.  If we can figure out how to address those imbalances, much of what ails us could just go away.

I always think about the example of stomach ulcers, which used to be blamed on stress and diet, when in fact it turns out that most are caused by a bacteria infection.  We were thinking about it wrong and treating it incorrectly, and I suspect that the more we learn about our microbiome, the more examples like this we'll find.

The microbiome is already a serious field of research.  The NIH Human Biome Project -- whose mere existence should illustrate how quickly the field is becoming mainstream -- is funding a number of demonstration projects.  MIT and Massachusetts General Hospital (MCH) just announced the launch of their joint Center for Microbiome Informatics and Theraputics.  The field is starting to generate significant investment.

Deloitte estimates that in 2010 consumers were already spending some $56b of their own money on "nutrition/supplements," despite the alarming lack of evidence of their benefits.  Imagine how much we'd be willing to pay to be able to manage our own microbiome.

So I'm wondering; if good health is about manipulating our microbiome, do we still rely on physicians -- or perhaps microbiologists instead?

Then there is gene therapy.  This effort to replace defect genes is still in the experimental phase, but is showing promise.  For example, there is an Alliance for Cancer Gene Therapy that hopes to fix the root problem -- defective genes -- without the need for traditional medical interventions like surgery, chemo, or radiation, each of which has its drawbacks.

Similarly, a company named Spark Therapeutics has just received an FDA "breakthrough-therapy" designation for a gene therapy that addresses a group of eye diseases called inherited retinal dystrophies (IRDs).  Fierce BioTech notes a number of other companies are also making big bets in gene therapy.

When gene therapy reaches a more mainstream status, should it be physicians who oversee it, or geneticists?

Well, certainly we'd still need physicians to do surgeries and other procedures, right?  Perhaps, but many of those, while technically impressive, can actually be viewed as markers of failure -- failure to diagnose earlier or treat more conservatively.  That's not through anyone's fault, as the techniques for earlier detection and less invasive treatment haven't always been there, but they may be available in the not-so-distant future.

Why get a hip transplant or go through back surgery when, say, our ability to regenerate bones or nerves might make those approaches obsolete?  Indeed, in a hundred years -- or hopefully less -- much of the current practice of medicine may look as archaic as medieval medical practices do to us.
The question is, will we be ready?

All is this not meant to bash the medical profession (although when I read about things like pain doctors routinely testing Medicare patients for angel dust simply because they get paid for the expensive tests, it's hard to refrain).  My big concern is how limiting the "practice of medicine" to the medical cartel can stifle disruptive innovations in health care, by forcing them to funnel through the established practitioners.  It's ostensibly for patient protection but often looks more like protection of income (see Stay Off My Turf).

Telemedicine should be forcing us to rethink our historical criteria from where we receive our care, just as physician alternatives and even advances in artificial intelligence should also be forcing us to rethink our reliance on physicians.  Instead, we're trying to make the new options conform to the old rules.

Yes, I know the AMA just approved the interstate compact proposed by the Federation of State Medical Boards to facilitate more interstate licensing for telemedicine, but even that proposal reduces the degree of difficulty from, say, a 9 (on a 1 to 10 scale) to maybe a 6 or 7.  It is a compromise that might have been progressive in the 1990's.  Not in 2014.

It is the kind of inertia that typifies our existing health care system..

With all the new kinds of approaches, I'll be happy if they still have to go through FDA approval, so that we still require some (relatively) objective testing about efficacy and safely.  What I don't want to see is their falling through the rabbit hole into our crazy Alice-in-Wonderland health care system, which is what I fear happens if we require that only physicians can dispense them and expect them to be covered by health insurance.  That's the wrong way to go.

When Google starts selling their nanoparticles, and they or someone else starting selling a maybe home 3D printer to produce the necessary corrective actions that the personal health AI prescribes, I hope they're selling them direct-to-consumers.  More importantly, I hope that the medical-industrial establishment doesn't succeed in demanding control.

I have no doubt that there are still going to be physicians in our future health care system.  However, if we truly want innovation in our health care system -- and it's not like anyone is particularly happy with our current one -- then we have to stay focused on our health, even if it means displacing the central role physicians have always played.

As entrepreneur Elon Musk says, when it comes to innovation, start from "first principles."


  1. the physician of the future will be more of a personal health consultant. She will coordinate all the various data streams and treatment regimens. She will interpret results and recommendations to the patient. Medicine will never be reduced to an algorithm; it will always be part art, part science. We need to begin training our physicians to be artists first!

  2. Just saw two related articles:

    1. RingMD offers telemedicine from doctors anywhere in the world (http://mobihealthnews.com/38356/ringmd-launches-global-focused-telemedicine-app/). How will our antiquated licensing approaches address that?

    2. It's not just bacteria that we'll be using -- also viruses (http://www.nytimes.com/2014/11/19/science/viruses-as-a-cure.html?ref=science). One way or another, biochemistry becomes much more integral to our health care.