Five years ago, President Obama began the largest regulatory overhaul of US healthcare since Nixon, expanding coverage and radically redefining how coverage is purchased. In his 2015 State of the Union, Obama delivered a different kind of disruption, announcing the creation of a Precision Medicine Initiative, a $215 million genetic database that will make it possible to tailor diagnostics and therapies to patients’ individualized conditions. The New England Journal of Medicine called the announcement “visionary”.
The president’s announcement builds on a global trend changing the balance of power in our healthcare system. Initiatives like precision medicine firmly place the patient, rather than the provider, at the centre of medicine. In the universe of healthcare, this is a Copernican revolution.
In his new book *The Patient Will See You Now* Dr. Eric Topol, a cardiologist and Director of the Scripps Institute of Translational Medicine, argues that advances in our knowledge of the genome, coupled with the advent of the smartphone, herald the democratization of the discipline. He describes a world in which every one of us will have a personal “Smartphone Doctor,” allowing patients to diagnose, test and monitor themselves. Topol sees a future where patients will be empowered by tools that will function like a medical Geographic Information System — a personalized “Google map” for your health status. The GIS will have many sources and outputs. Patients (not doctors or hospitals or government) will own the system, and doctors will be partners in responding to it. He describes this as a movement towards evidence-based medicine and away from “eminence-based medicine”.
Topol cites hundreds of excellent examples already in practice — from low-cost smartphone microscopes in sub-Saharan Africa to wearable devices that track patient activity and systems to better manage chronic disease. Many of us have seen the step-counting bands on our friends’ wrists or appreciate being able to email or skype our family doctor, but Topol’s book reveals the enormous diversity and sophistication of the new tools that are now easily and cheaply available to patients.
Topol aims to be a medical Marshal McLuhan (one of his heroes). He describes how technological change is enabling an entirely new way of promoting wellness, preventing disease, and treating patients. He believes that we are at a pivotal moment in the history of humankind: “But instead of the Gutenberg press it’s the smartphone.” Drawing on his deep understanding of current clinical practice, he argues convincingly that mobile technology will “prove to be immeasurably transformative for the future of medicine.”
The scope of the change required to implement Topol’s patient-centered revolution in medicine is enormous. It will require a complete overhaul of health system organization, funding, and regulation. But it is inevitable. Consumers have already lived through this type of fundamental system change from physical to virtual and mobile services in banking, travel, retail and other industries. Soon it will come to health care. New entrants into health care delivery such as retail pharmacies and telecoms will compete and quicken the pace of change, creating new competitors for the established players.
Yet Topol’s book underplays how these new technologies, welcome as they are, might lead to inappropriate and unneeded care. As “smartphone doctors” close the information gap between patients and physician, new tensions will arise. If we put “smartphone doctors” (labs, scanners, and the “molecular stethoscope”) in the hands of patients they are going to ask for follow-up tests, many of which might be unnecessary and costly. We have to be careful not to repeat the overtesting and overtreating of the past generation.
How do we ensure the pendulum of power doesn’t swing so far in the direction of “patient power” that it displaces both eminence *and* evidence? How do we promote the patient without demoting the doctor? How do we prevent newer forms of “digital snakeoil” from taking the place of the old? The tension is obvious and points to the continuing need for expert arbiters in the system, able to combine the new information with a knowledge of the various links in the system of care.
Physicians and health care institutions do not fade into obscurity in this new vision, any more than banks have faded into obscurity because of online banking. Rather they will be compelled to reinvent themselves. Rather than the “high priests” of old, providers must become facilitators and coaches, trusted prescribers and translators of information, independent advisers of appropriateness. The task is huge, but vital.
This blog originally appeared in the National Post.