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Can Technology Deliver Better Health Care?


This is SCIENCE FRIDAY. I'm Ira Flatow. If you have trouble sleeping, your doctor might send you to a sleep lab and spend $3,000 a night to chart your sleep cycl. Or you could do the same thing at home with a commercially available headband, which wirelessly transmits your sleep data to your smartphone for under a hundred bucks.

That's just one of the cost-saving technologies one of my next guests writes about in his book "The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health Care." And - a look at how genetic testing, along with digital devices like your smartphone, might improve and personalize your health care.

But even if technology cuts the cost of your health care, will it improve the quality? And in an age where you barely get any face time with your doctor, would this mean even less? What do you think? Our number is 1-800-989-8255, 1-800-989-TALK. You can tweet us @scifri, and talk about digital medicine.

Let me introduce my guest. Dr. Eric Topol is the author of "The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health Care." He's also the director of the Scripps Translational Science Institute in La Jolla, California. Thanks for being with us today, Dr. Topol.

DR. ERIC TOPOL: Thanks very much for having me, Ira.

FLATOW: You're welcome. Dr. Reed Tuckson is executive vice president, and chair of medical affairs, for UnitedHealth Group in Minnetonka, Minnesota. And he joins us from Minnesota Public Radio. Good to talk to you, Dr. Tuckson.

DR. REED TUCKSON: Thank you, it's a real joy to be here.

FLATOW: Thank you. Dr. Arnold Relman is a professor emeritus of medicine and social medicine at Harvard Medical School, in Boston. He's also former editor-in-chief of the New England Journal of Medicine. Welcome back to SCIENCE FRIDAY, Dr. Relman.

DR. ARNOLD RELMAN: Thank you, Ira.

FLATOW: Thank you. Eric, let me begin with you. You write in your book about the digitized human being. What is that, and how is that going to give us better health care?

TOPOL: Well, the way we practice medicine today, Ira, is at the population level. We haven't had individualized data. We have, you know, one-off blood tests or procedures, but we don't have ways to get granular. So for example, knowing one's genome sequence or having wearable sensors for the particular metric of interest, whether it's blood pressure or blood glucose or things like that, imaging that's portable, that can be, you know, in a pocket that is high resolution, equivalent to what you would get in hospitals, we have new ways, new tools to make this big transition from a population-based medicine to individualized basis. And I think that's quite exciting potential.

FLATOW: So those two already exist on our smartphones and iPads and things like that, sensors?

TOPOL: Well, we've all seen how - yeah, I think that these tools do exist. You in your opening gave one example of being able to monitor brainwaves through looking at your smartphone display. And that's just the beginning. Now we can do this with glucose and blood pressure and virtually every physiologic metric, as well as for example having the key genetic information that would interact with prescription medicines to avoid major side effects or to get the right drug or the right dose for a particular individual.

FLATOW: Reed Tuckson, as the head of the UnitedHealth Group, the cost of health care, I'm sure, is important to you. Do you believe this will bring down the cost of health care?

TUCKSON: I think that these are important tools along our journey. I am very excited by the opportunities for personally relevant information to be - to help people identify what their opportunities are to affect the prevention of disease, the management of disease once it is manifested, much more effectively. And I think that's a very good thing.

I'm also excited by the capability of these tools to assist physicians in making more evidence-, science-based and personally appropriate decisions with and on behalf of their patients. So that's a good thing. The challenge, of course, in all of this, will be, though, how effectively we can integrate these tools appropriately into the prevention system and the clinical care system.

And that's going to require a great deal of judgment, maturity, wisdom, thoughtfulness on the part of all players in health care. But at the end of the day, these are exciting developments that give us reason for encouragement.

FLATOW: Arnold Relman, you became a physician in 1946. It seems like almost a whole different era, before the discovery of DNA, computers, things like that. What is your view on all of this medical technology? Is it better for the patient?

RELMAN: I'm not sure. I think in some ways it surely is and has already been demonstrated to be better. But I think however dazzling and impressive this new technology is, I don't think it's going to revolutionize the practice of medicine the way Eric suggests.

I think that medicine is not going to go away, and I think that we will still need the person-to-person contact between well-informed, compassionate doctors and their patients.

FLATOW: And you think that's going to become more limited as people look at their own output from these devices on their own, maybe their laptops, maybe they even upload it to their Facebook page.

RELMAN: I'm not sure. I think that remains to be seen. I have some reservations about the depiction of a future patient who is consumed by constantly watching sensors talk to his smartphone about the physiological and biochemical changes in their own bodies and worrying about what the genome, their particular genome might portend about their future health.

I don't think that patients are going to be motivated to do that all the time, and I don't think that they're qualified, they're ever going to be able to interpret - with all the information on the Internet that they have, that they're going to be able to interpret that information as well as their physician.

FLATOW: Eric Topol, in your book you talk about how patients might turn into what you call cyberchondriacs will all this information.

TOPOL: Right, and I think that's what Bud is alluding to, that potential. I mean, we had that same potential when the Internet got started with medical information on it and questionable quality and people making diagnoses of themselves by looking at information that was misleading. But this is a different story because this is one's own data.

It's not surprising to hear Bud Relman's contrarian views, but I think we need to be getting ready for a whole new era of medicine because this is so much like the Gutenberg printing press story, where it's the doctor knows best, and the medical priesthood, that's paternalism.

But now when individuals have access to their relevant data, sure there's opportunities and concerns regarding it being used in a negative or promiscuous way, but when it's used appropriately, that individual has new insight. And just like in the Middle Ages learning how to read, this is about consumers, the public, the individual having new insights and now a parity and getting out of this era of information asymmetry, where the doctors had the domain of the information.

This is going to be a whole different look, and I don't think that in fact changes medicine, the need for it. It just creates a different model of partnership, of parity, and I think that's really important. Still we need doctors for sure, for their knowledge and savoir faire and guidance, but it's going to be different when patients have their relevant data.

TUCKSON: I think that, Ira, one of the key things here is that medicine is not going to be immune from the trends that are happening in our society. The availability of this personally relevant information that gives people data and feedback that is specific to them, that helps to capture the educable moment and then provides them with support services to guide them along a path that they need to undertake in their own best interest.

Those things that are happening in other industries across the broad domain of life are inevitably going to be there for people. I think that Dr. Relman is appropriate in his caution for how will this change the dynamic between a patient and their physician, which is - has always been the essential dyad of how health care has been delivered.

And I think that this will require certainly some changes in capacity and certain changes in thinking between how physicians interact with patients. And I certainly agree with Dr. Relman that we don't want to turn patients into their own physician in the sense of making extraordinarily complex decisions without guidance.

But they also - it is true that overwhelmingly, there are decisions that people are making today and often making poorly that compromise their health or frustrate their health. And so I think it is a good thing for them to have available not only information and data but also empowerment tools and support.

FLATOW: Well, let me give you an example. People talk about being overweight. Obesity is one of the great scourges of our present society. What if you had, as one of your devices, it lets you, the health care company, know when I'm eating the wrong food. My weight is going up, I'm eating the wrong kinds of sugary substances that I shouldn't be eating, and does that give you the power then to say I'm not going to insure you? I can see what you're eating every day. I'm not going to insure you anymore if you keep that kind of diet up.

TUCKSON: I could not imagine a scenario, really, where we will get to the private employers or the people that offer Medicaid benefits or Medicare benefits, sort of taking those kinds of draconian positions. What I think you will see is - and what we are seeing quite dramatically present today in health insurance, is that those who are offering those health care benefits, the people that are providing benefits to their constituencies, are giving incentives to their members that say if you can achieve personally relevant goals, important goals, then we will help to make that - give you an incentive for achieving those goals.

And now what we have are the tools that are necessary to assist people in getting that done.

RELMAN: Ira, I agree with much of what my friends, Dr. Topol and Dr. Tuckson, are saying. But I would point out to your listeners that it's a matter of balance. I don't see what Eric calls a creative destruction of medicine. Medicine's not going to be destroyed. Medicine will continue to play an important role, and that's because no computer, no instrument can really care for patients.

That's what the essence of medicine is. And to care for patients, you need an intelligence human being, a well-informed, compassionate physician who is able to operate, of course, in a health care system that encourages him or her to act in an appropriate way.

FLATOW: We've got to stop there. We'll pick it up after the break. Stay with us. We'll be right back after this short break.


FLATOW: You're listening to SCIENCE FRIDAY. I'm Ira Flatow. We're talking this hour about the future of medicine with my guests, Dr. Eric Topol, author of "The Creative Destruction of Medicine"; Dr. Reed Tuckson, executive vice president, chief of medical affairs for UnitedHealth Group; Dr. Arnold Relman, former editor-in-chief of the New England Journal of Medicine.

Dr. Relman, you were talking about how the need for doctors is never going to go away. Well, could they not be integrated into the system here?

RELMAN: Yes, of course, I think doctors will be increasingly aided, as Eric says, by the wonderful new technology. There's no question that doctors can do much more, can be much more effective, with the help of computers and wireless devices of all kinds, and undoubtedly by using knowledge gained from the sequencing of each individual person's genome.

But I think there are limitations to how much this will change the practice of medicine, and it certainly won't eliminate the need for physicians. There is clear agreement that no computer alone can be as effective in the diagnosis or management of a patient as can a computer-assisted, competent physician.

We need both the technology that Eric is talking about and a physician, but the basic nature of medical care is not going to change.

TOPOL: If I could respond, Ira, to a couple of those points. First of all, you know, I think Bud is too literal in this term creative destruction. It comes from (unintelligible). It comes from the concept of transformation via radical innovation. I don't think anyone could question that we have serious problems with health care and medicine today.

A lot of people, of course, claim it's completely broken, but there are a lot of issues, and one of the biggest ones that you've already touched on is cost, the imprecision, the waste in medicine, because we don't have adequate data and information on each individual.

So this is an extraordinary, hyper-innovative potential. Now, no one is suggesting, certainly I'm not, that this is uncoupled with the important critical role of physicians, who will need to be more empathic than ever, because there will be this temptation to treat the DNA results or the scan or the sensor data, and that of course has to be done holistically with the patient.

And that whole element, critical aspect of compassion, has to be folded in. So I think when we have now access to a supercomputer, like Watson, who can go through two million pages of content in three seconds, that is just what I think Bud's touching on, is that assisted - that is, this digital technology capability that is just extraordinary to assist physicians in making very difficult diagnoses, for example.

So I think there is clearly this hybridization of medicine, yes, but with extraordinary evolving, rapidly evolving technology.

FLATOW: Reed Tuckson, let me just, I'm going to direct a question to you, and I'd be very happy if you'd answer, then you can make your point, please. What about - are we going to be creating another class of people who can't afford these devices, who don't have the smartphones and can't get the same sort of medical care as all these people who do have them?

TUCKSON: One of the great things we are seeing and learning about the proliferation of these digital devices, smartphones and so forth, not only in this country but certainly around the world, is that in fact there is a ubiquitousness to this. Poor folks are using these technologies just as much as others.

And in fact, in other countries, where the poverty is the rule, these become the solutions to equalizing the gap. So I think this is not going to be a major rate-limiting step.

What I think here, if I try to make it real for the average person who's listening to the show today, is where I think we really do come out in agreement. Eric talks about the asynchronicity of information and the imbalance of information. In the old days, the doctor had all the information, and the patient had very little. And the patient would go to the physician and get - essentially it would be imbalanced in terms of that patient-physician relationship.

Today the patient will be coming in with lots more information that is very specific and very relevant to them as an individual. And now the patient-physician relationship is going to be based on one where the patient is seeking the physician's judgment.

Judgment becomes extremely important here, and so now we really are in a partnership. So what I hope is that your listeners would be excited and engaged to have information, the facts, the best science about their conditions, facts about their own behavior, facts about their clinical condition, and then bring that information into the therapeutic arena with their physician and now engage in a true conversation that not only is based on best science but is also based on the judgment and wisdom of the physician, as well as based upon the values and needs and culture and desires of the patient.

Together they now may be able to reach better outcomes for that individual.

RELMAN: Ira, may I interject something here?

FLATOW: Please go ahead, Dr. Relman.

RELMAN: I think that Eric and Reed and I basically agree on the importance of giving patients more information and on - and empowering, thereby, a more integrated and useful cooperation between patients and doctors. There's no argument about that. I totally agree with them.

Where we may disagree, where I think there is some serious uncertainty about what's in Eric's wonderful book, is I doubt very much that individualized information about each individual patient is going to be as powerful an innovative factor in future medical care. I think that the knowledge of one's own symptoms and signs and what's in the literature is not going to be that important in changing what patients do and how they're treated.

And more important, I think that information, genomic information, is not going to revolutionize the diagnosis or the prevention or the treatment of disease or revolutionize the use of most medications. There are only a few diseases that are caused by a single - relatively few in the universe of many diseases - that are caused by single gene mutations and that can be predicted from knowing the existence of those mutations.

Most of the common diseases, like asthma or diabetes or high blood pressure or coronary artery disease, are what are called multi-factorial, that is to say many factors other than genomic variations influence their development and their occurrence.

And we're not anywhere near being able to confidently predict the occurrence of these diseases from such information or how they're to be treated or prevented.

So I think there's a lot of over-enthusiasm and premature enthusiasm about what's called individualized or personalized medicine. That's where I think Eric and I may disagree, although I repeat: I think Eric's book is a tour de force of useful new information. I learned a lot. And I think he's to be congratulated on telling us a lot about the new technology and the new genetics.

But I think he may be too enthusiastic about his predictions of what's going to happen in the future.

FLATOW: Let me go to the phones, to Austin(ph) in Sand Point, Alaska. Hi, Austin, welcome to SCIENCE FRIDAY.

AUSTIN: Hey, thanks, Ira, for taking my call. My question centers around the idea of, you know, technologies advancing. There's nothing to stop it. So what is, like, the AMA or the medical schools doing right now to prepare doctors who are active right now or upcoming doctors for this new technology and to better work with it to make better diagnosis?

FLATOW: Yeah, are doctors - good question. Are doctors already, people who practice now, already in the loop, know what's happening, getting their offices up to speed, or do we have to still teach them? And is this new digital medicine being taught in medical schools today?

TOPOL: Well, the answer for that is unfortunately it isn't being taught, for the most part. In fact, there's only a couple of schools across the United States that have really up-to-date genomics curriculum, have anything to do with the whole field of wireless medicine. So we're not prepared. It's a very significant problem that we're facing.

But just as digital - the digital world has invaded every other walk of life like education, that does afford an opportunity to get curriculum that would be set up not just for medical schools, but for the hundreds of thousands of U.S. physicians, who are already out there in practice, to get them up to speed. So I think the opportunity is there to, again, harness this digital infrastructure.

FLATOW: Reed Tuckson, is there - you talked about using incentives instead of punishments. Is there an incentive to get doctors and their offices that you can see?

TUCKSON: There is a - an incentive now that - and through some leadership through the federal government and others to incentivize physicians to adopt electronic medical records, which is - are - is a very key component in all of this strategy. And so the good news is that as a result of this incentivization, that we are seeing a much rapid - more rapid adoption of electronic medical records.

Today, about 55 percent of physicians in the country have electronic medical records. The use of those are - is more or less complete or incomplete across that 55 percent. But the encouraging news is that 35 percent are suggesting that they will incorporate electronic medical records - those that don't have them - 35 percent in the next two to three years.

So we are seeing movement in this space. And a lot of that movement will inevitably be, of course, that the young physicians that are entering the profession are themselves broad users of social networking, texting, smartphone applications, accelerometers on their digital devices, sensor-based technologies and so forth so that, inevitably, the young physician of today is the digital-literate human being, along with their peers.

FLATOW: You know, the more I - I've spoken to some young physicians about this, and they are coming from a digital-literate background. And because they are digitally-literate, they're fearful of what they know happens to digital information out there on the Internet. They're afraid to let their own patients' notes become public or share them with their patients because they know, being involved in the Internet, these things can pop up anywhere.

TUCKSON: The issue of trust in the data stream is absolutely critical, Ira, and I'm glad you put your finger on it. This is one of the biggest risks for whether this movement will go forward fully expressed. If we are concerned and have reason to concern for the protection of our information and/or the misuse of it in society, then, of course, this will not move as fast as some of us would like it to move.

RELMAN: Yes, I agree with what Eric just said. I think that issues of privacy are very difficult to solve in the new electronic era. In response to the listener's question, the listener's question, let me say that, to my knowledge, the great majority of medical schools now expects students to use computers in the course of their education. And physicians - as opposed to my era before computers were invented, every doctor learns how to use a computer and learns how to use the computer to help his or her practice. The question is how that's going to be used and whether it's really going to improve the quality of medical care. That's the issue.

FLATOW: This is SCIENCE FRIDAY from NPR. I'm Ira Flatow, talking with Dr. Eric Topol, author of "The Creative Destruction of Medicine," Dr. Reed Tuckson, who is of UnitedHealth Care Group - the UnitedHealth Group, and Dr. Arnold Relman, former editor-in-chief of New England Journal of Medicine.

In just a couple of minutes that I have left, are you optimistic we're going to see this all being integrated carefully and with these steps about privacy? Or is it going to be a learning experience as we go along, with hit and miss here and there?

TOPOL: I would say, Ira, that the whole issue is a trade-off, that if there is overriding, overwhelming benefit of having human beings' relevant data digitized, you know, these various tools that we've been discussing, there will always be, just like when anything is digitized, the risk of a breach of privacy, hacking, lack of security. So everything has to be done to minimize the latter. But if there is such extraordinary benefit, then, without question, this will move forward because here we have a fundamental change in - where medicine can go and be much more precise.

And going back to one of Bud's earlier points about the concern that it won't really be changing, when you can start to predict an asthma attack before a person even has any symptoms, or when you can similarly predict a heart attack days or weeks before it happens, that's really transformative.

And so we have 70 million people in the United States with high blood pressure. Half of them don't have very good control. When they can have their blood pressures being shown on their smartphone every minute, without any effort, and getting that blood pressure under better control to avoid strokes and heart attacks, that's changing. So that's where, I think, a lot of this data and information could really seed a revolution.


RELMAN: Well, Ira...

TUCKSON: And I guess I would say that I'm - I guess I would say that I'm excited about it in the sense that the great thing about innovation is innovation is - it blossoms and blooms out on its own. So this is a trend that is not - you can't put the genie back in the bottle.

At the end of the day, though, let us not be seduced by technology. Technology is a tool. Technology is a tool that has to be applied as a part of an overall strategy and an overall effort. And so as long as we don't get overwhelmingly seduced by the technology, but are able to apply these tools in intelligent ways, then I think we have something. Inevitably, people are going to be using these tools. Physicians will have access to patients who have them, and physicians themselves will have it. Now, it is time for us to get creative and thoughtful.

FLATOW: Dr. Relman?

RELMAN: My feeling is that as exciting and as innovative and useful as the new technology will undoubtedly be, and I do not argue this point, I believe that the greatest improvement in American health care and the greatest benefits to the health of the American people will be gained more from changes in the system of health care, the way we organize and pay for health care and the way doctors practice rather than simply through technological advances.

FLATOW: All right, mate, that's the last word. Dr. Arnold Relman, former editor-in-chief of the New England Journal of Medicine, Reed Tuckson, executive vice president and chief of medical affairs for UnitedHealth Group, Dr. Eric Topol is author of "The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health Care." Thank you all, gentlemen, for taking time to be with us today. We're going to take a break. When we come back, we're going to talk about "Immortal Bird." Stay with us. I'm Ira Flatow. This is SCIENCE FRIDAY from NPR. Transcript provided by NPR, Copyright NPR.