Dr. Eric Topol.. on CBS.. showing mobile devices proactive for heart monitoring..
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Aloha, patty
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by patty » Fri Apr 17, 2015 9:22 am
by Skip » Fri Apr 17, 2015 3:19 pm
by patty » Fri Apr 17, 2015 4:40 pm
Skip wrote:The TED talk was interesting. I couldn't help from stopping to think that all this monitoring is great, but it isn't that preventative. Topol says that 80% of those aged over 65 in the U.S. have 2 or more chronic diseases. The simple and elegant answer to the problem is the adoption of a WFPB eating protocol and some exercise. All this high tech monitoring will simply let everyone know how sick they are in real time which doesn't really solve the problem.....
The AMA was upset that I was calling out the organization on its paternalistic efforts to prevent individuals from obtaining their own DNA results without having to go through a physician, and shortly after that interview was published, I received a call from Dr. James Madera, the CEO and executive vice president of the AMA, who wanted to discuss this issue. He started out the phone call with the line, “Eric, we’re not your father’s AMA.” But it was only on researching the history of paternalism in medicine did I realize the deep roots of this problem with the AMA. This wasn’t just your father’s AMA; it was your great-great-grandfather’s AMA.
The original 1847 Code of Ethics is telling. 28
Here are some of the salient passages in order of appearance, with a few key words highlighted, from the Introduction and the Code: 1. As it is the duty of a physician to advise, so he has a right to be attentively and respectfully listened to.
2. It is a delicate and noble task . . . to prevent disease and to prolong life; and thus to increase the productive industry and, without assuming the office of moral and religious teaching, to add to the civilization of an entire people.
3. Impressed with the nobleness of their vocation, as trustees of science and almoners of benevolence and charity, physicians should use unceasing vigilance to prevent the introduction into their body of those who have not been prepared by a suitably preparatory moral and intellectual training.
4. The most learned men and best judges of human nature.
5. A physician should not only be ever ready to obey the calls of the sick, but his mind ought also to be imbued with the greatness of his mission.
6. They (physicians) should . . . unite tenderness with firmness, and condescension with authority, as to inspire the minds of their patients with gratitude, respect and confidence.
7. A physician should not be forward to make gloomy prognostications, because they savor of
empiricism, by magnifying importance of his services in the treatment or cure of the disease.
8. The life of a sick person can be shortened not only by the acts, but also the words or the manner of a physician.
9. Medicine, confessedly the most difficult and intricate of the sciences, the world ought not to suppose that knowledge is intuitive.
10. A patient should never weary his physician with a tedious detail of events or matters not appertaining to his disease.
11. The obedience of a patient to the prescriptions of his physician should be prompt and implicit. He should never permit his own crude opinions as to their fitness, to influence his attention to them.
12. A patient should never send for a consulting physician without the express consent of his own medical attendant.
13. Patients should always, when practicable, send for their physicians in the morning, before his usual hour of going out, for, by being early aware of the visits he has to pay during the day, the physician is able to apportion his time in such a manner as to prevent an interference of engagements. Patients should also avoid calling on their medical adviser unnecessarily during the hours devoted to meals or sleep. They should always be in readiness to receive the visits of their physician, as the detention of a few minutes is often serious inconvenience to him.
14. A patient should, after his recovery, entertain a just and enduring sense of the value of the services rendered to him by his physician, for these are of such a character, that no mere pecuniary acknowledgment can repay or cancel them.
15. There is no profession, from the members of which greater purity of character, and a higher standard of moral excellence are required than the medical; and to attain such eminence, is a duty every physician owes alike to his profession, and to his patients.
16. There is no profession, by the members of which eleemosynary services are more liberally dispensed, than the medical.
17. The benefits accruing to the public and indirectly from the active and unwearied beneficence of the profession, are so numerous and important, that physicians are justly entitled to the utmost consideration and respect from the community.
Much of the language conveys the sense of a self -congratulatory orgy; nobility, authoritative command, and eminence are pervasive. The AMA has revised this document several times, but the original Code of Ethics has set a lasting tone.
The first revision did not occur until more than fifty years later, in 1903. The Principles of Medical Ethics included only a slight change in the statement on the readiness of physicians for calls of the sick . 29 Instead of “imbued with the greatness of his mission” (# 5 above) there was a downgrade to “should be mindful of the high character of their mission and of the responsibilities they must incur in the discharge of above). An important statement about communication to the patient was added: “A solemn duty is to avoid all utterances and actions having a tendency to discourage and depress the patient.”
It is striking that the first mention of informed consent by the AMA did not occur until the 1957 revision, 31 where it was stated that “a surgeon is obligated to disclose all facts relevant to the need and the performance of the operation,” and “that an experimenter is obligated, when using new drugs and procedures, to obtain voluntary consent of the person.” 31 It is indeed hard to imagine it took from the origin of medicine until 1957 to formalize the concept of informed consent and the right of the patient. Nevertheless, it did.
Later AMA revisions and documents on ethical affairs in the 1980s included two statements that give considerable authority to physicians based on their judgment. On informed consent, the AMA contended that physicians should be entitled “to treat without consents when the physician believes the consent would be ‘medically contraindicated,’” and maintained that “disclosure need not be made when risk disclosure poses such a serious psychological threat of detriment to the patient as to be ‘medically contraindicated.’” 32 Of note is the progressive shortening of the AMA codes and policies: in 1847, it was 5,600 words; in 1903, 4,000; in 1912, 3,000; in 1957, 500; and by 1980, reduced to 250. 28,29,31,32 While the words were markedly reduced overall, there were never any added to raise awareness that patients need a voice.
Topol, Eric (2015-01-06). The Patient Will See You Now: The Future of Medicine is in Your Hands (p. 25). Basic Books. Kindle Edition.
Paternalism, Priests, and Phones
Realizing that is a bold assertion, now I’d like to get more specific about how we connect the dots from the first chapter on medical paternalism and the current chapter. I’ve purposely gone in chronological order, as the “doctor knows best” era began around 400 BC, almost two millennia before printing came about. BPP the high priests were among the only people who could read and had access to books. The priests, nobility, and highly affluent were the only literate individuals, an exclusive basis for knowledge and power . Martin Luther authored his 95 Theses in 1517, profoundly challenging the church’s authority. 41 Obviously, he wasn’t writing about medicine, but a few of his theses may be considered relevant to the topic at hand: (1) There is no divine authority for preaching that the soul flies out of purgatory as soon as the money clinks in the bottom of the chest; (2) Why are there penitential canon laws, which in fact, if not in practice, have long been obsolete and dead in themselves?; and (3) It is foolish to think that papal indulgences have so much power that they can absolve a man even if he has done the impossible and violated the mother of God.
We’ve already seen the connection between doctors and God. It’s in the original caduceus symbol, the godly nature of medical care; it’s in “patients must honor doctors since they have received their authority from God.” 42 While God anointed Aesculapian physicians in the ancient Greek era, it’s still even strongly implied in the original 1847 AMA Code of Medical Ethics. 43
Accordingly, the power of doctors can be likened to that of religious leaders and nobility. This dominance was derived from knowledge and authoritative control of medical information in general, and each patient specifically. Luther confronted the supreme authority of the church, with over three hundred thousand copies of the 95 Theses that were widely distributed. 44 We’ve never seen such a discrete challenge to the medical profession, but we’ve not had the platform or landscape for that to be accomplished. Until now.
Just as the model of a communications revolution explains the future impact of Gutenberg’s press, we are about to see a medical revolution with little mobile devices. For the flow of information will be radically different. Instead of the command ritual of data going first to doctors and trickling down to patients, this deep -rooted practice is about to be turned upside down. Serving as the channel, smartphones will convey all the relevant data pertaining to an individual directly to that individual (or in the case of children, to the parents)— from personal health records, biosensors, lab tests , scans, genomics, and environment. The smartphone readily connects to the cloud and will increasingly connect to supercomputer resources. In many cases, smartphones will play a role well beyond a passive conduit, such as actually performing the lab tests or medical scans, parts of the physical examination traditionally done by a doctor, or processing the data that is graphically displayed or used for predictive analytics.
But the role of smartphones in this electronic communications revolution is not only indexed to the individual. We’ve already seen the beginnings of managed competition among individuals using their smartphone data from sensors, such as quantifying sleep, glucose, or blood pressure. This can and will be further amplified across a wide gamut of physiologic metrics and through the use of social networks. At a much larger level, the extensive sharing of little device data— from single individuals to create huge population cohort information resources— presents new opportunities for massive open online medicine (MOOM ). Conceptually, we’re talking about bottom-up medicine, which was never possible until we had the tools and digital infrastructure to pull it off.
Smartphone spread of information isn’t confined to transferring medical data. It’s a means of rapidly amassing and galvanizing people who are fed up with the current state of health care. Of waiting an average of sixty-two minutes to see the doctor, leading to the full toll of seven minutes of seeing the doctor for a return office visit, often without eye contact (a unilateral sighting). Of experiencing a serious error while in the hospital, such as acquiring a dangerous nosocomial infection or receiving the wrong medication with a critical side effect. Of seeing the hospital bill that reflects the notorious chargemaster with ludicrous fees. Of being responsible for ever-increasing copays for prescription medications, doctor visits, insurance, or any consumption of health care resources. So just as we have seen emotions , ideas, pictures , and videos transmitted via smartphones to prompt political protests, the increasing frustration and vexing aspects of health care today may influence a bottom-up movement, propelled by smartphones and social networks , for improving the future of medicine.
Looking back at Table 3.1 and specifically honing in on the medical smartphone attributes, it is notable that there are already tens of thousands of medical apps that have been developed by a network of worldwide developers. What’s most amazing, however, is not the sheer number, but the staggering creativity. Who would have thought we could digitize breath via a smartphone to detect cancer? Or measure critical lung function parameters by breathing into its microphone? Or use a microfluidic attachment to run hundreds of routine lab tests with a drop of fluid? How about repurposing a phone into a high-powered microscope or into multiple physical examination devices, such as an ophthalmoscope or otoscope? Such devices empower both the patient and the doctor.
As we’ll see, medical smartphones will create unprecedented DIY applications. Since these devices operate anywhere there is a mobile signal, the chance for egalitarian access to portable medical technology throughout the world is especially promising and exciting— for example, using the camera and text messaging to screen for skin cancer. Ironically, much of the progress in medical smartphone use is occurring in the developing world, which not only starts at a lower tier of technological capability, but also is without the hindrance of perverse reimbursement incentives. The opportunity to lower health care costs with unplugged medicine is starting to get proof of concept, and will be reviewed in depth subsequently. But when the role of hospitals and clinics are challenged via remote monitoring and virtual office visits, it is not hard to envision a major change in cost structure. And major resistance.
So the substrate for a new medical communications revolution is in place. I believe it is inevitable, but the timing of when this will be actualized is uncertain. We know how hard it is to change things in medicine, just as it is extremely difficult for religious rituals to be altered. For example, dating back to the eighth and ninth centuries in Europe, the priest faced the apse, the wall behind the alter, with his back to the people, praying in Latin, which few people in the Mass understood. 45 This particular orientation was known as “ad orientem.” 46 That could mean disorientation to the maximus . Although this ritual is still in practice in some churches in Europe today, it has largely been abandoned— since the 1960s. It only took one thousand years for the priests to typically face the people and use the native language. While doctors are not so good at using nonmedical jargon, still write prescriptions in Latin, and due to pressures in using electronic medical records are less good at facing the patient, there is a new path going forward.
Topol, Eric (2015-01-06). The Patient Will See You Now: The Future of Medicine is in Your Hands (p. 52). Basic Books. Kindle Edition.
The Road to Emancipation
One of my intellectual and visionary heroes is Marshall McLuhan, the original media guru, whom you will note has been widely quoted in this book . Back in 1962, he published The Gutenberg Galaxy: The Making of Typographic Man . 64 He provided remarkable insights on the impact of the printing press and subsequent forms of mass communication. This led him to propose, way ahead of their time, the concepts of a “global village” and “surfing” related to the accumulated body of recorded works of human art and knowledge. Even though it would be many decades before the Web existed, he foresaw the ability to rapidly and mutidirectionally move from one document to another in the electric age. He realized that it wasn’t about the technology per se, but that the people and their culture were reinvented by books and printed materials. McLuhan probably understood the impact of mass media better than and before anyone else, and realized that without the printing press there would not ever have been media and the world as he knew it and as it has further evolved today.
In a similar vein, there would not be democratized medicine without smartphones , along with the entire digital infrastructure that supports them. The culture stands to change dramatically once the tricorder comes online. In Star Trek’s vision of the twenty-third century, Dr. Leonard “Bones” McCoy used the handheld device to immediately diagnose disease with three input recording functions— GEO (geographical), MET (meteorological) and BIO (biological ) ( Figure 15.3 ). 65– 67 In 2015, just before Star Trek’s fiftieth anniversary, Qualcomm is awarding a $ 10 million X-Prize to the team that produces the best version of a modern tricorder. 68 There’s a big difference, however: this device isn’t meant to be used by Bones or a doctor, but rather a device that is fully operated by the patient.
Moving From Autocratic to Semi-Autonomous Medicine
We know the road to medical emancipation is within our reach. The technology to digitize human beings has required innovation; it’s here and continuing to rapidly evolve. But that’s relatively easy compared with its implementation and achieving the democratization of health care. So I propose the iMedicine Galaxy ( Figure 15.4 ) as a model to bring the requisite interdependent forces together and achieve transformation. Let me briefly review what we need from each of them.
The Large Employers The biggest companies have hundreds of thousands of employees and are paying billions of dollars a year on health care. Rather than having these companies leave the United States to reduce their tax burden to be able to pay employee health care costs (such as Abbvie or Medtronic) or go bankrupt (like General Motors), this book provides a far more attractive option. Lead the charge; buck the system. If they promote democratized medicine for all their employees, it would strip down the costs of care for office visits, hospitalizations, lab tests, imaging, and other diagnostic procedures. Why should these companies pay for an elaborate ultrasound study, with charges averaging $ 800–$ 1,000, when in most cases the necessary imaging can be done as part of a mobile-technology-driven physical exam , and essentially for free? Why are patients kept in the hospital or even admitted, at the $ 4,500 per day average fee, when they could have remote monitoring? Why pay for sleep studies in a hospital laboratory that cost at least $ 3,500 when they could be performed for free, at least a screening exam, in the patient’s home? Why haven’t such employers enforced all of the hundreds of Choosing Wisely’s modest but clear-cut recommendations of unnecessary tests and procedures ? 69 These are but some of the ways large employers can exercisetheir massive muscle to reduce costs and catalyze bottom-up medicine. They also can have marked influence over the big health insurance companies they hire, like United Health, Wellpoint, and Aetna, but no big company has moved to use it yet. If just one becomes a first mover, and challenges the status quo along with the baseless charges of “rationing,” this could take off.
Consumers It may be harder to mobilize the consumer base even though they are at peak frustration and have picked up a considerably higher burden of their health care costs in the form of “co-pays.” We know they want their data, want better engagement and interaction with their doctors, and are the prey for countless unnecessary tests and procedures every year. There hasn’t yet been the one big thing or the public figure with overpowering clout to rally the public. But that doesn’t mean it won’t happen. A large international survey of adult smartphone users in fourteen countries, including the United States, has shown that 80 percent of consumers want to interact with their doctors on mobile devices, and nearly 70 percent would prefer to get medical advice on their mobile devices instead of going to the doctor’s office. 70 , 71 The social network is in place; there are multiple precedents for a grassroots revolution. When Apple debuted their 2014 new software campaign that included the Health and Healthkit apps, it was called “You’re More Powerful Than You Think.” 72a They sure got that one right. Collectively, more like a sleeping giant waiting to erupt. The power of people indeed seems palpable when you see that parents of kids with muscular dystrophy are the key drivers in writing the regulatory guidance documents for new drug approvals 72b or the magnificent spike in research fundraising for the Amyotrophic Lateral Sclerosis Association driven by social media and the “Ice Bucket Challenge.” 72c
Government
Although tremendous political capital was used to get the Affordable Care Act passed, and access has improved as a result, nothing has been done to truly democratize American medicine. We have an outmoded Center for Medicare and Medicaid Services (CMS) with 140,000 codes for describing needed care, even nine for different injuries caused by turkeys. Estimates of fraud run as high as $ 272 billion per year, giving rise to the notion that the only people who love America’s health care system are its thieves. Tackling even a fraction of that fraud could free up the $ 40 billion investment needed to drive the use of interoperable electronic medical records that include each individual’s GIS. So too would doing something about CMS reimbursement, which needs a complete overhaul with proper information systems in place , and a simplified, rational system that fosters rather than suppresses consumer empowerment. Why does CMS reimburse $ 300 for a simple drug interaction genotype when it costs pennies to perform? And why doesn’t CMS negotiate pricing of drugs, devices, and diagnostics like every other country in the developed world? If you ask health policy wonks or legal eagles “why?” the answer is “that’s the law.” Well, it’s time to change the law.
Patient ownership of data also demands changes to the law. The White House continues to publish white papers on the “Consumer’s Privacy Bill of Rights” without any follow-up action. Protected ownership can only be asserted with new legislation. The Federal Trade Commission needs to be charged with proscribing the selling of an individual’s medical data without their unconditional consent. 73 If we cannot provide the absolute maximal assurance of privacy and security for each individual’s medical data, or if the government decides to effectively tolerate hacking, medical emancipation will never get started. New technologies to achieve this critical goal, such as quantum cryptography, 74a deserve careful consideration.
The Food and Drug Administration, while paying lip service to innovation, has done little to alter its regulatory approval processes to catalyze the ways that each individual can assume a greater role in their medical care. That’s why your smartphone isn’t as smart as it could be 74b in an ambiguous regulatory landscape. 74c It will be a hard and slow slog to new medicine without marked changes in the way innovation is recognized and encouraged, such as by faster reviews, conditional approval, and tight post-market electronic surveillance.
Surely, even if lack of progressive reimbursement and regulatory procedures in the United States means that democratized medicine does not take hold here, these frugal—and better —technologies will find homes in the rest of the world, where there are virtually no perverse incentives and immediate opportunities for nonlinear, leapfrog change. This has already been seen with multiple devices, including the modern handheld ultrasound stethoscope. The most far-reaching opportunity that lies ahead for governments around the world is the support and promotion of massive online open medicine (MOOM)— the planetary database of everyone’s de-identified GIS that enables matching and the best-known treatment and outcomes for all human beings.
Doctors and the Medical Community
With disinclination to change embedded in the medical community, reflected by the average time gap of seventeen years from innovation to adoption in medical practice, we need a cultural change. While digital native doctors just coming out of medical school or finishing residency training understand the sea change that is unfolding, there are millions of practicing physicians around the world who do not. We don’t have time to wait for a new generation of doctors and health care professionals to take hold. Cultural change is exceedingly difficult, but given the other forces in the iMedicine galaxy, especially the health care economic crisis that has engendered desperation, it may be possible to accomplish. An aggressive commitment to the education and training of practicing physicians to foster their use of the new tools would not only empower their patients, but also themselves. Eliminating the enormous burden of electronic charting or use of scribes by an all-out effort for natural language processing of voice during a visit would indeed be liberating. It’s long overdue for physicians and health professionals to be constantly cognizant of actual costs, eliminate unnecessary tests and procedures, 75a and engage in exquisite electronic communication, which includes e-mail , and sharing notes and all data. If financial incentives are needed, they may be well worth the investment.
Data Scientists
Government and recalcitrant doctors are major potential impediments, but the biggest bottleneck to advancing the field is unquestionably dealing with data. Here is the paradox: there is no shortage of data to capture and aggregate, yet we have a profound shortage of the people who can write algorithms, separate signals from noise, and actualize the full potential of computers to perform deep learning. While there are a relatively small number of such professionals in a world inundated with data challenges in every sector, health care has not been able to attract enough gifted individuals proportional to the size and importance of this field. The irony now is that data scientists are the ones being referred to as the “high priests.” 75b
The iMedicine Galaxy
Patients, companies, employers, doctors, government, data scientists: these major forces are like stars gravitationally bound in a galaxy , the movement of any one of them affecting all the others. What I have tried to convey here is that we have a new galaxy in the making. Just as the printing press was the great object around which modern culture has orbited, the smartphone and iMedicine are forcing a comparable transformation. There is a time ahead when every human being has the potential for the same access to medical care, provided they have a mobile signal, when medicine is no longer paternalistic and autocratic, when a reformation and a renaissance of medicine can take hold. Only then can we move from an era in which Desmore asserted, “medicine is not a science, [but] empiricism founded on a network of blunders” to a new medicine as a real data science with each individual capable of calling the shots, making the choices.
As with any model, particularly one that is going after a new, emancipated form of medicine, there will be no shortage of naysayers. They’ll say that it’s ill founded, underdeveloped, impossible, or even irrational. Yet technology to achieve this is accelerating; we have what were envisioned as futuristic, twenty-third century capabilities now. I consider it inevitable; the biggest question is the matter of timing. For centuries medicine’s galaxy has orbited the doctor. If just one of those major forces exerts itself, these changes could happen very quickly. Maybe Angelina Jolie will tip the scales and change medicine’s orbit. Or maybe it will be you.[/URL
Topol, Eric (2015-01-06). The Patient Will See You Now: The Future of Medicine is in Your Hands (p. 290). Basic Books. Kindle Edition.
by flabingo » Sat Apr 18, 2015 11:37 pm
by veg tom » Sun Apr 19, 2015 5:55 am
by patty » Sun Apr 19, 2015 9:43 am
The first step is to educate the public, teaching the truth about what we know about nutrition and the ravages of the traditional Western diet.
In my fantasies, for instance, I imagine a widespread use of the brachial artery tourniquet test (BART), which Dr. Robert Vogel used to such devastating effect to prove the vascular damage a single meal can cause. If public schools were forced to serve only meals that are BART-positive (i.e., maintaining normal artery dilation), if restaurants were required to inform us which menu items are BART-positive and which are BART-negative, if the labeling on all packaged foods carried information on their BART status, we would have gone a long way toward enlightening citizens and helping them make informed choices about enhancing or destroying their health. Although my BART fantasy may never come true, the basic point is that the place to start is definitely by enlightening the public.
Then, perhaps, we can slowly put in place some institutional changes. For instance, we can approach insurance companies, employers, and representatives of labor with a modest proposition: that heart patients targeted for the mechanical intervention of bypass surgery or stenting should first try twelve weeks of arrest-and-reverse therapy—plant-based nutrition plus, where necessary, cholesterol-reducing drug therapy. In fully compliant patients, we see angina disappear in just a few weeks, and stress tests may return to normal in eight to ten weeks, so the results would be clear to everyone involved: for the great majority of patients, the dangerous, costly mechanical intervention would be rendered unnecessary.
What I am proposing would require revolutionary changes in the world of medicine. My father used to observe that as long as medicine was practiced on a fee-for-service piecework basis, comprehensive preventive medicine would never become the driving force in a physician’s life. He was right. As I argued in Chapter 1, there are now no incentives built into the system to encourage the public to adopt healthier lifestyles. I once asked a young interventional cardiologist why he didn’t refer his patients for a nutrition program that could arrest and reverse their disease, and he replied with a frank question: “Did you know that my billed charges last year were over five million dollars?”
This has to change. The collective will and conscience of my profession is being tested as never before. Now is the time for legendary work.
Those of us who practice medicine must engage in a new covenant with the public. We must never underestimate the layman’s ability to adopt healthier lifestyles. We must tell the truth. We must relinquish the procedural focus of medicine and take pride in prevention. We must rejoice in conveying knowledge that empowers individuals to take control of their own health.
Esselstyn Jr. M.D., Caldwell B. (2008-01-31). Prevent and Reverse Heart Disease: The Revolutionary, Scientifically Proven, Nutrition-Based Cure (p. 110). Penguin Group. Kindle Edition.
by pundit999 » Sun Apr 19, 2015 9:58 am
UK, Canada, even less wealthy countries such as India and China will adopt this sooner than the US.by flabingo » Sun Apr 19, 2015 11:47 am
by bbq » Thu Dec 17, 2015 11:17 am
Besides the scale, Jillette also relied on the Withings Wireless Blood Pressure Monitor. At the time, he was on “six hard-core meds” to control his blood pressure. As he dropped weight at the rate of nearly a pound a day, the medications that had been keeping him alive were starting to kill him, he says. So each day he strapped on the cuff, which uploaded his blood pressure directly to his doctor.
“I’d put the cuff on, and my doctor would call me 15 minutes later and say, ‘Your blood pressure is crashing, get off that medication, it’s poisoning you,’” he says. “I don’t think it’s possible to do what I did if I had to drive to the doctor’s office every week to measure my blood pressure.”
Today, Jillette is medication-free.
All told, Jillette’s group of co-conspirators collectively lost several hundred pounds — and they’re not done yet.
by patty » Thu Dec 17, 2015 11:59 am
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