Don't Fear the Future of Medicine

An Interview With Eric Topol About His Book, 'The Patient Will See You Now'

; Eric J. Topol, MD


June 29, 2015

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Editor's Note:
In this episode, Dr Bob Harrington interviews Medscape Editor-in-Chief Dr Eric Topol about his book, The Patient Will See You Now (Basic Books, 2015).

Dr Harrington: Hi. This is Bob Harrington from Stanford University. Over the course of the past year I have had the pleasure and the opportunity to interview several authors in the medical space, largely physicians who have something interesting to say about the contemporary state of medicine, healthcare, and research. Today we are going to try to wrap all of that into one discussion.

I have the pleasure today of interviewing my friend and colleague, Eric Topol. We are going to talk about Eric's new book, The Patient Will See You Now: The Future of Medicine Is in Your Hands.

What struck me, as I read this book, is the possibility of delivering not just a different type of healthcare but a better type of healthcare, largely facilitated through two strategies, one of which is smartphone technology, which we will talk about with Eric; the second is the use of analytic tools to turn the data, collected through a variety of mechanisms, into useful information.

I want to talk with Eric about smartphone technology and healthcare, and about some of the analytic tools. I will ask him how this empowers patients to be more engaged and help lead their healthcare team. And I want to close with the issue of how to get traditional medicine to respond to these challenges and how to overcome some of the obstacles.

I am very honored today to be talking with my friend and colleague, Eric Topol. Eric is a professor of genomics and the director of Scripps Translational Science Institute in La Jolla, California. He is the author of The Creative Destruction of Medicine (Basic Books, 2011) and now of The Patient Will See You Now.

Eric, thanks for joining us here on Medscape Cardiology.

Dr Eric Topol: Sure, Bob. Great to be with you.

Dr Harrington: Let's jump right into it. After The Creative Destruction of Medicine, which you and I also discussed on this podcast, what led you to write The Patient Will See You Now? What was burning in you that said, "I have got to say this"?

Democratizing Medicine

Dr Topol: Because my first book was on digitizing medicine and digitizing human beings, I started to realize that that is just the beginning. You can do that and you get so much information about each person, that the next phase is democratizing medicine.

The book was really intended to pull together how to move forward in this momentous juncture in medicine where each person will have access to data that we didn't think was possible—how that can be a radical change in how healthcare will move forward.

Dr Harrington: I love the phrase "democratizing medicine." It captures what access to data has allowed us to do. Explain what you mean by that from the patient perspective, and then maybe we will get into the provider perspective.

Dr Topol: I started to have this realization after studying the Gutenberg printing press. I didn't really know all the nitty-gritty, but there is an amazing book—The Printing Press as an Agent of Change, by Elizabeth Eisenstein. Having read that book and all the research, I started to realize that what happened to democratize information back in the 1400s was what was going to happen in medicine in the 21st century. That is, by having this data through mobile devices, sensors, sequences, images, and the entire "Google map" of yourself, that that was going to be a liberation, a democratization. And, of course, it's not just something that is in the United States. This is flattening the earth. This is making medical data available to one's self anywhere there is a mobile signal. That parallel with something that happened several centuries ago is what inspired me that we can do this.

It is going to take time. This is not an easy mission but it is certainly now possible.

Dr Harrington: As a classically trained liberal arts student in my former life, as an English major undergraduate, I really love the analogy of the printing press; it took information that was held by a select group who could copy books and pass them on in a very narrow tradition, and made things widely available.

As you did your research into this, Eric, and you thought about not just patients but everybody and all of their healthcare data, any worry that there could be too much information coming to people, or is there no such thing as too much?

Dr Topol: There is a concern of not only too much information but of inducing cyberchondria. We have already lived through the Internet and the fact that people could look up other people's data, data that didn't apply to them, and all of a sudden [felt like] they had those diseases. The difference is that this is much more specific. It is getting your data and then, with algorithms and machine learning, you're going to be getting processed distillate contextually with your life that will basically help you. Instead of the one-off medicine that we have practiced historically, now we have real-time streaming in the real world for each person with their data.

It is a different look completely. As you alluded to, Bob, it is not the high priest and the affluent, the only people who had books. Now, everyone will have their medical information but some people won't want it. Some people would go cuckoo with their data, and a lot of seniors would be happy not taking charge of their data.

If people are "wired," it might not be good for them to get their vital signs continuously streamed to their smart watch. But, as it turns out, most people, something like 80%, really want their data and as much as possible—as long as they have it properly analyzed and it is kept secure and private.

Dr Harrington: One of the things I have had the opportunity to do is review some of the early writings of Eugene Stead as he conceptualized the data bank of cardiovascular information. A lot of what he talked about was the inability of the human mind to aggregate data into a useful manner for people to utilize.

What you are talking about takes the Stead vision a step further, because now not only do you have this aggregated population-level data coming from multiple sources, but you also can overlay your individual data in its longitudinal fashion with the whole population. And it really brings together this concept of n = 1 in population health.

Dr Topol: Drawing that Stead vision is right on. I wasn't even familiar with that but it is fascinating.

The point that you are getting at is that when you have such high definition of each individual's data and you start to pull that together, that is when you have a whole new ability to understand. It is like reverse epidemiology. It goes back to the individual, all of that learning.

When you look at the world, you say, how do you get 1.4 billion people on Facebook and we can't get that many people in a medical knowledge resource. How we treat each person is so segmented. What if we could actually learn from each person to help the next person? So that is another potent way that this new medical datafied world could move forward.

Ingrained Paternalism

Dr Harrington: Let's talk, Eric, a bit about docs like you and Eugene Stead—ahead of your time, in many ways. Part of what you talk about in your book is the challenges of getting the medical profession to respond. I think you have written a beautiful history of paternalism of the medical profession going back to its inception. I was pleased to note that you lament the older doctors, greater than 55 years, as being particularly recalcitrant—because at age 54, I wasn't in that group.

Do you want to comment on medical paternalism and how do we change?

Dr Topol: That was another big part of the research for the book because I couldn't understand where all of this came from. This sense of supremacy and the idea of ruling the roost; autonomy; and why the doctors and hospitals own the medical records. All these years, that was the way it was. Where did it come from?

I read everything I could. There isn't really a book about medical paternalism but there are lots of books about the history of medicine. This required quite a bit of reading before I could finally pull it together. This traces back to before Hippocrates at 400 BC, who said not to reveal anything; you might get the patient's disease by telling him what is really going on. So while Hippocrates did a lot of great things for medicine, he sure nurtured paternalism and the concept that the doctor knew best.

It was Abraham Verghese during his Stanford graduation commencement speech (2014) who talked about Imhotep, who was the first doctor, an Egyptian, and a priest several hundred years before Hippocrates. So this goes way back. Then in more modern times, back in the 1800s, the American Medical Association talked about the nobility of the doctors and all this stuff which I couldn't believe when I read their code of ethics. We have ingrained, deep-seated paternalism. The young docs, the digital natives who are just coming out of med school or in med school now, understand that that is not going to last because of the symmetry of information, and information is power.

Dr Harrington: What struck me about paternalism is the anecdote of your grandparents, who were both discovered to have metastatic cancer and nobody told them. And this is not the 1800s. This is in your lifetime when that attitude toward what patients should know prevailed. I suspect that other people have told you this as well, but that section of the book stunned me.

Patients in the Driving Seat

Dr Topol: Oh, it is just amazing to me. That was in the '60s; doctors were not allowed to use the word "cancer." They would not tell patients they had cancer.

While it is obviously better today (people get the diagnosis), it reflects the times we have been through and that we have a long way to go to eradicate paternalism—and it has to be done. Because people have access to their data through their mobile device, they will be generating a lot of the data. This is eventually going to squash paternalism because, basically, they are driving everything. That is, the ones who are willing (which I think is the majority). There will be a partnership model with the doctor rather than the way it is today; it will be the patient who says, "Would you like to see my data? Would you like me to share it with you?"

By the way, things are happening quickly. LabCorp allows anyone to order their own lab tests. A lot of things are happening where you can do your own labs through your smartphone pretty quickly. You can obviously get all of these medical sensors. We are not talking just about Fitbit® anymore. We are talking about glucose and blood pressure and the quantification of every physiologic metric of man.

Those are the data that are going to be generated by an individual, and it doesn't go in the electronic medical record. We need a home for these data. Hopefully we will find that, but over time, that is going to really drive change.

Dr Harrington: You refer to Elizabeth Holmes from Theranos, and she uses the same word that you do, which is "democratization." She wants lab tests to be controlled by the individual patient or person. You seem to have been quite struck by her.

Dr Topol: I got to meet her soon after Theranos became known, and I did her first video interview. I had the lab testing with the single drop of the blood just before I interviewed her for Medscape, and by the time the interview was over, I had 100-plus lab test results. It was remarkable.

But, you know, one of the things that is really interesting as an aside of this is that I had a finger warmer on to dilate the blood vessels in the finger and I didn't feel the little stick. Why haven't we used finger warmers for finger sticks all these years? Help me. Why do we have to induce pain?

Little things like that—no less the fact that they are giving back the lab data to the person. She is committed to that. But I don't think that going to a drug store, for example, is where this is going to land. I think that is a way station while, pretty soon, just like doing a home pregnancy test, we will be doing any test that is routine, from electrolytes to any organ function test to CBC. You will just do that yourself and then you get your algorithms embedded in your apps that tell you what it means.

These tests will interact with all of the other data coming from you and, as you already mentioned, no human being could analyze all that, and that is why there is this thing called a computer—to help you.

Dr Harrington: Near the end of the book you talk about the concept of deep learning, which I found one of the more fascinating parts of the book. When you tell docs that you are going to get people's Fitbit information, you are going to get blood work, and you might even see their social network on Facebook, they get overwhelmed. But they don't need to be overwhelmed because we are coming up with tools to deal with this. Do you want to talk a little about the concept of deep learning and how that is going to help facilitate this?

Dr Topol: Most physicians have been a little bit warped, because if you go in a hospital room, the alarms are beeping all the time and nothing is stored because we haven't had the luxury of real technology like companies such as Google, Apple, Microsoft, Intel, Qualcomm, and the list goes on and on. They are invading medicine.

As you probably know, many of them have made humongous investments in deep learning. What we have now is the ability to take all of this data and process it. This virtual medical coach in your smartphone that talks to you or sends you texts, or however you want to get the processing of your data, is going to be evolving pretty quickly now. There are already prototypes out there.

Deep learning is putting all of the data in context, looking at all of the interactions, and letting you know the reason why your blood pressure is starting to ascend and your weight has picked up and your glucoses are doing this. It is basically trying to crack the case on what is going on before you get off track.

That deep learning extends beyond the individual; when you feed into this computing capability all the data from individuals with a particular condition (or some connection), you will have an even more profound ability to predict things.

For example, seizures, heart attacks, strokes, autoimmune attacks, asthma attacks—these are going to be preventable from deep learning. If you have all of the data and you know where the trigger is for that individual, they can be warned before the event takes place. That is a particularly exciting part of the future of medicine.

Better Doctor-Patient Relationships

Dr Harrington: One of the topics that is related to this, Eric—as I talk to my colleagues, they say, "That is all well and good, but what is going to happen to me? Is this going to replace me?"

I think some of the early reviews of your book got your message wrong. My takeaway was that you see a stronger relationship potentially developing between an empowered patient with data and an empowered provider with analytic tools that help the patient understand that data, and they work together to provide better healthcare.

Dr Topol: I couldn't agree with you more, and I was pretty upset with a couple of the early reviewers who didn't get that. It looked like they hadn't read the book carefully.

As liberating as it is for patients, it is equally so for doctors. Physicians all around the world are overburdened trying to deal with all aspects of medicine, including the things that you don't want to get involved in (all of the administrative stuff).

But now, because of this capability of having data we never had before, generated by patients and with the help of machine deep learning, contextual computing, this is a great decompression of the effort of physicians. Moreover, the most important thing is that it increases the intimacy of the bond.

I have tried to practice this type of medicine in recent years as much as I can. When you do a hand-held ultrasound and you are looking at it with the patient in real time, showing the patient what their heart looks like and what is going on with the valve or the thickness of their heart muscle or function, they never saw that stuff before. They never had real-time data of their blood pressure or their heart rhythm, whatever it was, and they are seeing it themselves. This ability is shifting responsibility to the patients, but I believe that this heightened engagement leads to a much tighter—and I really think more intimate and healthier—relationship.

We get rid of the autonomy, we get a better partnership going, and I think it is actually a very exciting phase for the future of medicine from the standpoint of both doctors and patients.

Dr Harrington: That is the message that I want to leave our listeners with. I was very impressed by how this new world, if you will, or even the current world, can liberate providers to get a more intimate sense of the relationship with their patient. I love it when somebody brings to me their recording of their blood pressure over the course of a month because it is so much more granular. It is so much more contextual when I look at the time of day that their blood pressure changes, when I look at when their meals are, when they are sleeping. It is a phenomenally useful tool for providing counsel about how they might manage their blood pressure better.

Dr Topol: Well, that is because you are a young doctor.

Dr Harrington: Right. At age 54.

Dr Topol: I wish all doctors were really enthusiastic about patients generating data. Not yet, but they will be as this moves along. I think it is going to really be a fantastic future for medicine and for all involved.

Dr Harrington: I could not agree with you more, Eric, and as someone who has followed your observations with interest over the years, thank you for writing the book. It really is a tremendous addition for both patients and the provider, and I would recommend that people give it to their patients. I would also recommend that our colleagues read it, because I think that there are observations and insights there that they will find useful in their own practices.

Dr Topol: Thanks very much, Bob. I really appreciate that.

Dr Harrington: I have enjoyed talking today with my friend and colleague, Eric Topol, professor of genomics and the director of the Scripps Translational Science Institute. He is the author of The Patient Will See You Now. Eric, thanks for joining us here on Medscape Cardiology.

Dr Topol: Thank you.


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