If my kid can’t bring peanut butter to school, yours shouldn’t be able to bring preventable diseases.
Last week at the State of the Union address, President Obama introduced the masses to something called Precision Medicine. Generally speaking, it is a theory that we should customize and tailor medical treatment for each individual. Of course, that’s exactly what we should do and the direction we should go.
Western doctors have a few tools at their disposal to treat their patients:
- Lifestyle change advice
That’s about it. So let’s think about which tools are most effective.
Doctors aren’t so great at getting people to change their lifestyle in a significant way. Most medical students get one or two lectures in behavioral modification. Western medical doctors just aren’t experienced in this kind of intervention. It’s a much bigger initiative than the three office visits the average American makes to the doctor every year. Doctors are terrible at preventing lifestyle diseases, but great at fixing things when they are structurally broken.
Doctors are getting better and better at surgeries and procedures. If you have a structural problem, we’re increasingly using more computers, robots, cameras, 3D imaging, 3D printing, technological instruments and such to get you all fixed up and on your way. Doctors, their hardware, and their procedures work magic and it’s only getting better. Exciting times indeed. Those lucky surgeons!
Now we’re left with medications. For the last 15 years or so, the FDA has approved a very small number of new drugs that are actually new drugs. It’s been around 10 new kinds of drugs (“new molecular entities”) every year for the past 15 years or so. It costs between $2.6 billion and $11 billion dollars to develop a new drug, which has increased roughly 150% in the past decade. It takes roughly 12 years to go from first test to medical cabinet. And the chance of approval from formal pre-clinical testing to approval is 1 in 5,000. Keep in mind, the definition of a drug according to the FDA is a substance that causes an intended effect in the human body that’s better than placebo. It can be 5% better or 90% better. As long as it’s statistically significantly better than a placebo and has been demonstrated as “safe” for humans. But even the most popular drugs have very little actual effect on the population. It takes over 500 people taking Lipitor to prevent one death or serious medical complication. There’s an axiom in medicine that for most medications, 1/3 of people are helped, 1/3 of people are not affected, and 1/3 of people are harmed by a medication’s side effects.
Personalized medicine wants to target the 2/3 of people who are not affected or are harmed by medications. If we can know who won’t respond or will be harmed by a medication, we can try another medication. And therein lies the rub. If we reduce a medication’s potential market by 2/3, we have to significantly increase the number of medications in our arsenal. But the cost of developing new drugs is becoming prohibitive and the economics of new drug development can’t sustain an increasingly smaller market all enabled by “Precision Medicine."
We sure are in a pickle.
Every test has risks. There are risks of false positives and false negatives. For example, a false positive is when an HIV test says you have HIV, but you really don’t. And a false negative is when the HIV test says you don’t have HIV, but you really do. Every test that doctors perform have very well-described false negative and false positive rates.
Tests come in all kinds of different flavors from blood tests and x-rays to physical exams. Anything that generates some sort of data can be considered a test. Zeke Emanuel recently wrote in the New York Times that we should skip our annual physical exam because it’s simply a bad test:
In 2012, the Cochrane Collaboration, an international group of medical researchers who systematically review the world’s biomedical research, analyzed 14 randomized controlled trials with over 182,000 people followed for a median of nine years that sought to evaluate the benefits of routine, general health checkups — that is, visits to the physician for general health and not prompted by any particular symptom or complaint.
The unequivocal conclusion: the appointments are unlikely to be beneficial. Regardless of which screenings and tests were administered, studies of annual health exams dating from 1963 to 1999 show that the annual physicals did not reduce mortality overall or for specific causes of death from cancer or heart disease. This lack of evidence is the main reason the United States Preventive Services Task Force — an independent group of experts making evidence-based recommendations about the use of preventive services — does not have a recommendation on routine annual health checkups. The Canadian guidelines have recommended against these exams since 1979.
And here’s the kicker:
Some are actually hurt by physicals, because healthy patients who undergo an exam sometimes end up with complications and pain from further screening or confirmatory tests.
Fascinating isn’t it? Ever think that an annual physical exam could harm you? The bottom line is that it’s simply not a very good test at all. It’s too blunt a tool.
But there’s a new kind of test on the horizon. It’s called wearables. There’s a big push from the wearables industry to force some sort of wearable ubiquity upon us.
But these wearables are, in fact, tests. They are tools to generate data just like blood tests, x-rays and physical exams. Some of these data-generating tools are exceptionally helpful and some are actually harmful not only for pain and suffering, but also for initiating costly further testing. They will have false positives and false negatives. They may diagnose diseases that will never actually harm us. They may diagnose diseases that we can’t do anything about. They may provide early diagnoses and force us to live with anxiety longer than we need to.
As wearables tread ever closer to tracking more medical values (blood glucose) instead of health values (steps taken), they may actually do more harm than good and we should be open to this possibility. Everybody thought that physical exams were helpful. They’re not and they may be harmful. We might find ourselves in the same predicament with wearables triggering further unnecessary and costly testing. I’m not saying it’s probable, just that it’s possible.
I spent the New Year in Colorado. I snowmobiled up to the Continental Divide where this photo was taken. It’s quite possibly the toughest photo of me you’ll ever see.
For years we, and others, have struggled to describe and define Sherpaa’s healthcare delivery model. It’s not telehealth. Telehealth concepts currently in existence simply don’t go far enough. First, telehealth “visits” are transactional and typically video visits between an unknown, random doctor and patient. They are confined by a doctor-patient time slot and once the transaction is over, for further communication, you have to pay for a new time slot. But, in real life, health is an ongoing conversation with ongoing events, new updates, and needs that can’t really be forced into a time slot. Second, tele means “to or at a distance” referring to physical distance. But our doctors nor our patients feel like they are “at a distance.” As we’ve seen for years from the apps that have changed how humans communicate like Facebook, GMail, Whatsapp, Instagram, OKCupid and many, many others, online communication draws people closer and enables efficiencies. Sherpaa is also not the medical home model. It’s not an in-person brick and mortar, team-based, primary care physician-led, interaction. And finally, it’s not traditional healthcare. There are no transactional, synchronous, in-person visits within the confines of a time constraint and an exam room.
Sherpaa is an entirely new genre of healthcare delivery.
It’s not traditional healthcare. It’s not a medical home. It might be considered telehealth, but it’s telehealth on steroids and realized to its full potential.
Sherpaa healthcare delivery is:
written rather than oral
online, asynchronous and convenient
virtual when appropriate, and in-person when needed
always on and omnipresent (desktop and mobile)
quality-driven and checklist-based
powered by our team of doctors
Sherpaa is a virtual medical practice that closes the loops of healthcare and cost-effectively optimizes the health of a population. It is an online, virtual practice that functions much like the traditional, doctor-patient relationship, but instead of all the communication happening within the confines of an exam room, communication happens in a written, secure, and online format at the convenience of the patient. We take a checklist-driven history, order lab and/or radiology tests as needed, receive those results, treat appropriately, or refer you to be seen in person. Whether or not we treat you or refer you, we follow up with you to make sure you are at your best. As a patient, you can log in to your cases and see exactly what was said, view your test results, and your well-organized treatment plan.
Sherpaa is an entirely new genre of healthcare delivery and one the world has not yet seen. It is always-on telehealth. Sherpaa is the future of healthcare, delivered today.
“Between 1991 and 2008 teen pregnancy in this country had an annual decline of just 2.5% a year. In the next four years, coinciding with airing of the programs, the decline tripled to 7.5% per year. The study showed that exposure to the television shows had a sizable effect with 5.7% of the overall 17.6% decline being directly attributable to the show. That means almost one-third of the dramatic total decrease in teen pregnancy can be linked not to state and local public health efforts, not to the work of the National Campaign to Prevent Teen and Unwanted Pregnancy, but to a television program created for profit and primarily known for churning out fodder for tabloid magazine spreads and future sex tapes. That makes MTV reality television the single biggest factor in bringing the teen pregnancy rate to its lowest point in decades. The Teen Mom effect has a greater impact than condom exchanges, traditional sex education and abstinence-only education combined. Public health policy has been trumped by the accidental triumph of MTV.”