Topol and Agus on the Future of Medicine

Speaker after speaker at the January 26, 2012 Care Innovations Summit in Washington, DC concluded that increasing the quality and decreasing the per-capita cost of health care is the dominant political, social, and economic issue of out time. More than one expert called for a “jailbreak.” Before January 26, “jailbreak” for me meant either an obscure English reality television show or an expression applied to overriding the software limitations deliberately placed on computer systems for security or administrative reasons. The speakers in DC seemed to be calling for a jailbreak out of the prison of the status quo of the American health care delivery system and into an era of digital medicine and understanding the ill patient as a complex emergent system that does not need to be fully understood to be cared for.

Two new books make the case that American medicine is at an inflection point and about to undergo “its biggest shakeup in history.” Eric Topol, MD in The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health Care (New York: Basic Books, 2012) is no fan of the traditional approach which he labels as “conservative to the point of being properly characterized as sclerotic, even ossified.” David B. Agus, MD in The End of Illness (New York: Free Press, 2011) applies systems biology to his field of oncology and concludes: “Cancer is not something the body has or gets; it’s something the body does.”

Medicine is notorious for being slow to catch up to the rest of the world. The following statement by H. Thomas Johnson, former President of the Academy of Accounting Historians, indicates that medicine is even more recalcitrant to change than accounting:

“Quantum physicists and evolutionary biologists now believe that it is best to describe reality as a web of interconnected relationships that give rise to an ever-changing and evolving universe of objects that we perceive only partially with our senses. In that systemic view of the world nothing is merely the sum of the parts; parts have meaning only in reference to a greater whole in which everything is related to everything else. The Cartesian/Newtonian worldview has influenced thought far beyond the physical sciences, and accounting is no exception. Double entry bookkeeping and the systems of income and wealth measurement that evolved from it since the 16^th century are eminently Cartesian and Newtonian. They are predicated on ideas such as the whole being equal to the sum of the parts and effects being the result of infinitely divisible, linear causes. Why should accountants continue to believe that human organizations behave like machines if the scientists from whom they borrowed that mechanistic worldview now see the universe from a very different perspective? Never again should management accounting be seen as a tool to drive people with measures. Its purpose must be to promote inquiry into the relationships, patterns, and processes that give rise to accounting measures”

Having graduated from Case Western Reserve School of Medicine in 1980 and having trained at UCSF as an academic anatomic pathologist, I am steeped in the traditional approach to health care. The biomedical model reduces every illness to a biological mechanism of cause and effect, and physicians diagnose diseases and then treat them. Health is defined as absence of disease. The patient story and experience is subjective and untrustworthy in comparison to the test results emanating from my pathology laboratory, which are objective and true. Generalists are replaced by specialists who regard cure as the only important goal. And pathologists are the most important of the specialists because treatment selection and administration has to await the diagnosis rendered in the pathology laboratory.

Agus labels the traditional approach “the germ theory of disease, which dominated, and in many ways defined, medicine in the twentieth century.” “The treatment only cared about the invading organism…it didn’t care to define or understand the host (the human being).”

Agus, an academic oncologist and founder of both a proteomics and a genomics biotech start up company, replaces the medical status quo with a system biology approach. “It is important to approach your health in general from a lack of understanding. Honor the body and its relationship to disease as a complex emergent system that you many never fully comprehend.” His conclusion that one does not need to understand cancer to control it is controversial.

In discussing the recent Susan G. Komen/Planned Parenthood controversy, Susan Love, MD argues that finding the cause of breast cancer is far more important than refining the screening techniques we use today. Dr. Love concludes her article with “We must move breast cancer advocacy to the next level, beyond screening for cancers that are already there, even beyond the cure, to finding the cause. That is true prevention.” (http://www.nytimes.com/2012/02/07/health/breast-cancer-screening-matters-but-prevention-is-the-real-goal.html)

The human body is so complex that we may never really understand it, but the systems biology theory has already yielded new ways of helping patients. Zoledronic acid is a drug that affects bone metabolism to reduce fractures, but does nothing to cancer cells. And yet this drug has decreased breast cancer recurrence by 36%, presumably because it changes the environment of bones so that cancer does not spread so readily. Avastin is too large a molecule to get past the blood-brain barrier, but Agus describes how it is being used experimentally to treat some malignant brain tumors, perhaps by changing the pressure in the brain. The Mayo Clinic and Cincinnati Children’s Hospital have studied how the cytochrome P450 superfamily of genes affects the metabolism of drugs used in treating mental illness. Although we do not fully understand what causes these diseases, the GeneSightRx test for five genes has allowed physicians to tailor drug therapy to 12,000 patients’ individual metabolism.

Topol would replace the traditional approach to medicine with digital medicine. For Topol, digital medicine is now possible because of the convergence of genomics, wireless sensors, digital imaging, information systems, social networks, the ubiquity of smartphones, and the unlimited computing power of cloud server farms.

The iPad and the Kindle have forced us to come to grips with what it means to digitize a book. What does it mean to digitize a human being? The technology exists for every personal health record to contain our genome, our physiologic metrics such as blood pressure and brain waves measured morning, noon, and night, digital scans of any organ, and the cumulative radiation exposure from every scan and x-ray. When one realizes that all of this information can be readily available from our smartphones connected to the cloud, physicians will soon have a window into each person’s health and wellness that has implications across the continuum of care. In the emerging digital medicine, information at the point of care will ensure the most up to date treatment and the avoidance of the medication and coordination errors that plague current American health care delivery. There are 13,600 medical diagnoses, 4,000 medical procedures, and 6,000 medications currently available. This is precisely the kind of complex data problems that digital technology solves.

Topol, a cardiologist, proposes digitizing humans to identify those susceptible to heart attacks. Sequencing the genome for cardiac risk variants could be combined with identifying arterial lining cells that are sloughed off into the blood stream during the early stages of a heart attack. Individuals who are at high risk could be monitored with an implanted nanosensor that communicates with the patient’s smartphone. Topol even envisions eventually having the nanosensor automatically release medications in response to high levels of worrisome markers.

Agus, Topol and the speakers at the Care Innovations Summit all foresee a new paradigm of health care that will enable us to decrease the per-capita cost and increase the quality of care that Americans receive. Instead of waiting until a disease has developed or the patient visits the doctor once a year to diagnose and treat an illness, the patient will know what diseases are likely due to genetic predisposition and he will be monitored with wireless and implantable sensors so that the disease can be predicted and prevented. Instead of considering health to be absence of disease, we will embrace the WHO definition of a state of complete physical, mental, and social well-being. Instead of focusing on cures, we will concentrate on managing chronic diseases.

Agus and the others contemplate the end of disease which seems a little overly optimistic but intriguing nonetheless:

“Take a moment to imagine what it would be like to live robustly to a ripe old age of one hundred or more. Then, as if your master switch clicked off, your body just goes kaput. You die peacefully in your sleep after your last dance that evening. You don’t die of any particular illness, and you haven’t gradually been wasting away under the spell of some awful, enfeebling disease that began years or decades earlier.”