Wednesday, May 9, 2012
Dr. Eric Topol and the creative destruction of medicine
Before reading Dr. Eric Topol's Creative Destruction of Medicine, I wasn't sure what to expect. Dr. Topol, a cardiologist with a background in genetics, was a prominent figure in the take-down of Vioxx. He was at the Cleveland Clinic back then, around 2004, and has since moved to direct the Translational Science Institute at Scripps. He was a few years ahead of me in academic medicine and, by almost any parameter, far more successful.
He's a TED speaker, I knew. From the TED bio: "Eric Topol uses the study of genomics to propel game-changing medical research." His work sounds exciting! I first read of the new book in a recent, tech-minded interview in Wired. Seemed like it might be all theory, no touch-y, little reality. With this lead-in, I wasn't quite prepared to like this book, although I was interested.
Dr. Topol's book is fantastic. I couldn't put it down because it's chock-full of good, critical ideas about clinical medicine. The title, "Creative Destruction," is a reference to Joseph Schumpeter's theory of radical transformation through innovation. In Chapter 1, he outlines the "Digital Landscape" and explains, simply, how a convergence of advances in technology over the past 40 years, like personal computers, cell phones, the Internet, connectivity and instant access to data, have set the stage for a dramatic shift in medical culture and practice. Doctors, for some reason, have been slow to adapt digital technology to health care, but this is changing, fast.
One theme that emerges through the book is the capacity for technology by "knowing" and processing so much real-time information about each person's condition to inform more effective, individualized treatments. This comes up in his critique of evidence-based medicine and later, when he considers progress in molecular oncology and again, in a section on the pitfalls of old-fashioned, large clinical trials involving many (hundreds or thousands of) patients unlikely to benefit.
Dr. Topol's comfortable writing about the intersection of science and medicine as few physicians are. He describes several clinical episodes, like when the first patient with a stroke received tPA, a clot-dissolving agent. The point is, he's been there, at some of the world's best hospitals, where innovative treatments have been applied. But he's also seen first-hand disappointment, too. This grounds the work. There's a long chapter on "Biology" which offers, among other insights, a realistic critique of genetic information that many doctors don't understand. He identifies value in hypothesis-free research, and considers high-throughput screening.
I should mention two provocative details, among many. One appears in Chapter 3, on "empowered" medical consumers. At the Cleveland Clinic Foundation, where he'd worked and served on the Board of Governors, Dr. Topol observed busy, otherwise-occupied trustees who contributed significant time and money to the hospital. One reason they did so, he says, was so they might have access to the best doctors "in case anyone in my family or I get sick" (p. 50). He cites flaws in popular hospital ranking systems, like U.S. News & World Report, and offers tips for how to find a good doctor for a particular condition, like checking publications in Google Scholar and looking for senior authors of highly-cited papers. He writes: "The heterogeneity of the quality of care is not adequately appreciated, and all too often consumers accept the convenient, easy alternative ... If this involves a physician or surgeon who does procedures or operations, it is essential to ask for the exact number of procedures performed per year and cumulatively over his or her career ..." (pp. 52–53)."
The point here is that physicians are not machines. Some are more capable than others, and the quality of care received depends on the doctor's training, experience and other human qualities.
Another gem, in Chapter 11, pertains to the "science of individuality." We're at a threshold, Dr. Topol says, of eliminating ignorance in medicine. For doctors and informed patients who happen upon this review: idiopathic, essential and cryptogenic diseases will be gone. Instead, we'll have conditions defined molecularly or, even if not understood, rooted in the concept of n=1. He writes: "... a new body of data that can be derived from any individual, both at baseline and after an intervention ... This opportunity leverages the immense molecular biological, physiologic, and anatomic data that can be determined for any individual, and reinforces that the ultimate goal of an intervention is to have a markedly favorable impact on each n-of-1, rather than the current model, which emphasizes population medicine with the relatively small chance that any individual may derive benefit."
What he's saying is that the more quickly and inexpensively we can gather and process details about a patient's medical condition, the more cleverly we can apply treatments designed to help, even in the absence of large trials.
I love this idea.
This post originally appeared at Medical Lessons, written by Elaine Schattner, ACP Member, a nonpracticing hematologist and oncologist who teaches at Weill Cornell Medical College, where she is a Clinical Associate Professor of Medicine. She shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology and as a patient who's had breast cancer.
Labels: Elaine Schattner, guest post, innovations, Medical Lessons, new technology
posted by Elaine Schattner, MD at
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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:
Albert Fuchs,
MD
Albert Fuchs, MD, FACP, graduated from the
University of California, Los Angeles School of Medicine, where he
also did his internal medicine training. Certified by the American
Board of Internal Medicine, Dr. Fuchs spent three years as a
full-time faculty member at UCLA School of Medicine before opening
his private practice in Beverly Hills in 2000.
And Thus, It Begins
Amanda Xi, ACP Medical
Student Member, is a first-year medical student at the OUWB School
of Medicine, charter class of 2015, in Rochester, Mich., from which
she which chronicles her journey through medical training from day
1 of medical school.
Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and
general internist in the Division of General Internal Medicine at
Johns Hopkins. His research interests include doctor-patient
communication, bioethics, and systematic reviews.
Controversies in Hospital
Infection Prevention
Run by three ACP
Fellows, this blog ponders vexing issues in infection prevention
and control, inside and outside the hospital. Daniel J Diekema, MD,
FACP, practices infectious diseases, clinical microbiology, and
hospital epidemiology in Iowa City, Iowa, splitting time between
seeing patients with infectious diseases, diagnosing infections in
the microbiology laboratory, and trying to prevent infections in
the hospital. Michael B. Edmond, MD, FACP, is a hospital
epidemiologist in Richmond, Va., with a focus on understanding why
infections occur in the hospital and ways to prevent these
infections, and sees patients in the inpatient and outpatient
settings. Eli N. Perencevich, MD, ACP Member, is an infectious
disease physician and epidemiologist in Iowa City, Iowa, who
studies methods to halt the spread of resistant bacteria in our
hospitals (including novel ways to get everyone to wash their
hands).
db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating
medicine and the health care system.
DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about
health topics for patients and health professionals.
Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more
than a decade and is an Associate Professor of Medicine at an
academic medical center on the East Coast. His time is split
between teaching medical students and residents, and caring for
patients.
Everything
Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science,
medicine, health and healing in the 21st century.
FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the
Internal Medicine Residency and Assistant Dean of Scholarship &
Discovery at the Pritzker School of Medicine for the University of
Chicago. Her education and research focus is on resident duty
hours, patient handoffs, medical professionalism, and quality of
hospital care. She is also an academic hospitalist.
Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings
of medical practice and the complexities of hospital care,
illuminates the emotional and cognitive aspects of caregiving and
decision-making from the perspective of an active primary care
physician, and offers behind-the-scenes portraits of hospital
sanctums and the people who inhabit them.
Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the
University of North Carolina School of Medicine, and the Program
Director for the GI & Hepatology Fellowship Program. He
specializes in diseases of the esophagus, with a strong interest in
the diagnosis and treatment of patients who have
difficult-to-manage esophageal problems such as refractory GERD,
heartburn, and chest pain.
I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an
interest in basic and clinical science and education, with
interests in noninvasive monitoring and diagnostic testing using
novel bedside imaging modalities, diagnostic reasoning, medical
informatics, new medical education modalities, pre-code/code
management, palliative care, patient-physician communication,
quality improvement, and quantitative biomedical imaging.
Informatics
Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical
Informatics & Clinical Epidemiology, Oregon Health &
Science University, posts his thoughts on various topics related to
biomedical and health informatics.
David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned
authority on nutrition, weight management, and the prevention of
chronic disease, and an internationally recognized leader in
integrative medicine and patient-centered care.
Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of
hematology and medical oncology. His blog is a joint publication
with Gregg Masters, MPH.
KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites
for influential health commentary.
MD
Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of
medical practice, including controversies in the doctor-patient
relationship, medical ethics and measuring medical quality. When
he's not writing, he's performing colonoscopies.
Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics
in medicine, health care news and culture. Her views on medicine
are informed by her past experiences in caring for patients, as a
researcher in cancer immunology, and as a patient who's had breast
cancer.
Mired in MedEd
Alexander M.
Djuricich, MD, FACP, is the Associate Dean for Continuing Medical
Education (CME), and a Program Director in Medicine-Pediatrics at
the Indiana University School of Medicine in Indianapolis, where he
blogs about medical education.
More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice
internist, returns with "volume 2" of his personal musings about
medicine, life, armadillos and Sasquatch at More Musings (of a
Distractible Kind).
Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a
small community hospital in Connecticut. His blog is a series of
musings on medicine, medical care, the health care system and
medical ethics, in no particular order.
Reflections of a Grady
Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being
a doctor in a community hospital in Atlanta.
The Blog of Paul Sufka
Paul Sufka,
MD, ACP Member, is a board certified rheumatologist in St. Paul,
Minn. He was a chief resident in internal medicine with the
University of Minnesota and then completed his fellowship training
in rheumatology in June 2011 at the University of Minnesota
Department of Rheumatology. His interests include the use of
technology in medicine.
Technology in (Medical)
Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in
education, social media and networking, practice management and
evidence-based medicine tools, personal information and knowledge
management.
Peter A. Lipson,
MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and
teaching physician in Southeast Michigan. The blog, which has been
around in various forms since 2007, offers musings on the
intersection of science, medicine, and culture.
Why is American Health Care So Expensive?
Janice
Boughton, MD, FACP, practiced internal medicine for 20 years before
adopting a career in hospital and primary care medicine as a locum
tenens physician. She lives in Idaho when not traveling.
World's Best Site
Daniel Ginsberg, MD,
FACP, is an internal medicine physician who has avidly applied
computers to medicine since 1986, when he first wrote medically
oriented computer programs. He is in practice in Tacoma,
Washington.
Other blogs of note:
American Journal of
Medicine
Also known as the Green Journal, the American Journal of Medicine
publishes original clinical articles of interest to physicians in
internal medicine and its subspecialities, both in academia and
community-based practice.
Clinical
Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP
Member, associate program director at New York University Medical
Center's internal medicine residency program. Faculty, residents
and students contribute case studies, mystery quizzes, news,
commentary and more.
Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so
he can create an independent, clinician-reviewed space on the
Internet for physicians to report and comment on the medical news
of the day.
PLoS Blog
The Public Library of Science's open access materials include a
blog.
White Coat
Rants
One of the most popular anonymous blogs written by an emergency
room physician.
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