Precision Medicine, Patient Engagement: Your Questions Answered

Marrecca Fiore; Maurie Markman, MD, MS; Gregory R. Weidner, MD; Michael W. Smith, MD, MBA


November 24, 2015

Editor's Note: In September, Medscape held its first Medicine 3.0 event in New York City. The Town Hall-style discussion, which included a panel of physician experts, focused on the topics of Precision Medicine and Patient Engagement.

Ahead of the event, Medscape solicited questions on these topics from its members. Here are some of the responses provided to those questions by panel participants.

Question: If shared decision-making (SDM) is an element of patient engagement, what happens when patients make decisions that the physician legitimately feels are not optimal for their treatment? What should the physician's role be?

Gregory R. Weidner, MD: SDM is a collaborative process that allows patients and their providers to make healthcare decisions together, taking into account the best scientific evidence available, as well as the patient's values and preferences.

SDM should value the expert knowledge of the clinician and the individual preferences and priorities of the patient. SDM is particularly important in scenarios where more than one option exists, and each has benefits and drawbacks.

It is most important that patients fully understand their options in order to make a decision that suits their values and preferences. Counseling from a trusted healthcare provider is a key piece of this process, ideally supplemented by well-designed complementary tools to present the options in a balanced and unbiased way.

Patients will sometimes process the options and choose a path that differs from what the clinician would choose or recommend. As long as the physician is confident that the patient is fully informed and understands the potential risks and consequences, then I think that the role should be one of continued support, respect for the decision, and a willingness to revisit any decisions at the patient's request. If the patient's decision poses an acute or serious risk, that obviously needs to be communicated frankly as part of the decision process.

Question: How can primary care doctors help their patients take advantage of precision medicine?

Michael W. Smith, MD, MBA: The best way to help your patients benefit from the emergence of precision medicine is to ensure that you are on top of the latest technologies and have a full understanding of what is available and, importantly, what isn't. One day, the world of precision medicine will take off. That's not today.

While we've made much progress identifying genomic mutations that contribute to cancer, for example, we don't yet have effective treatments based on many of these findings. There are only a handful of relevant interventions from which a relative few can benefit. However, the information that patients read and hear will likely outpace the reality of what is available to them.

Primary care doctors will be faced with an increasing number of questions. More information leads to more pressure on docs to keep up. For now, we can all encourage our patients to seek enrollment in the Precision Medicine Initiative cohort program so that they can participate in this developing area of science and help all of us realize the benefits of this personalized approach sooner rather than later.

Question: How strong do you think the preventive and predictive components of precision medicine are? And how will physicians treat their patients differently if they incorporate precision medicine into their practice?

Maurie Markman, MD, MS: It is fair to conclude that at this moment in time, the overall impact of precision medicine, in general, and precision cancer medicine, in particular, on the overall health of the population or patients with a particular illness is quite modest. But that is really not the point. Precision medicine is NOT AN EVENT; rather, it is A PROCESS. By this is meant the goal of precision medicine is to increasingly focus on the molecular events that favorably or unfavorably influence the states of health and illness.

There will never be a "date" when one will somehow declare, "The age of precision medicine has arrived." Rather, we will absolutely continue to see our ever-increasing understanding of the basic biology of humans translated into small and (hopefully) larger clinically relevant advances in the prevention, early detection, and treatment of human illness.

Of course, a critical question that remains unanswered today is how the massive amount of clinically relevant "data" can be translated into action on the level of the individual physician dealing with a single patient. The need for a robust decision-support strategy in multiple areas of medicine is palpable. When these decision-support tools are developed and their utility subsequently validated, I see precision medicine becoming a far more relevant component of routine clinical practice in oncology and throughout the practice of medicine.

Question: Sometimes patient engagement is a challenge for the physician, particularly when the patient arrives with numerous printouts of information from nonscientific sources. How can physicians deal with that in the time allocated for the patient visit?

Dr Weidner: In my opinion, the patient who arrives with printouts has already demonstrated a key attribute required for successful management of their condition. That is, he or she is activated about his or her condition and has shown a willingness to understand various diagnostic and therapeutic options. This patient is also demonstrating that he or she trusts his or her clinician to provide individualized context to the patient's personal research.

Ideally, the physician would leverage this engagement and trust by gently and respectfully evaluating the available options in a process of SDM—including some options from "nonscientific sources."

As we evolve toward new care models, much of this dialogue can and should migrate to synchronous and asynchronous channels of communication that support team-based, collaborative care. That way it won't feel like yet another task crammed into the already overburdened office encounter.

Question: Patients will have a lot of information about their health that their smartphones allow them to track, but it will be too much for a doctor to go through. What's the plan?

Dr Smith: First, if you accept that the data are here to stay, your new open-minded approach will make it much easier on you. Second, be proactive with your patients and talk to them about the type of data that would be useful in improving their care. A new survey from New York University Langone Medical Center[1] shows that 58% of smartphone users have downloaded health apps, which are primarily fitness- and nutrition-related. And most use them daily. That's a great deal of useful data that could help create health in their lives if used effectively.

Primary care physicians are ideally suited to move this conversation in the right direction as long as we're involved in the dialogue. Ask your patients if they use health apps. If so, pinpoint the data that would help you provide better care. That will lead to a targeted, personalized conversation that is good for both patient and doctor.

Clinicians and practices can also provide education on optimal ways to make sense of online and printed information—with handouts or links about how to discern reliable information on the web from questionable content. Understanding how to access and filter health information is a core competency for healthcare consumers and patients in today's world. And physicians can and should help them on this path.

Question: Regarding precision medicine, do you feel that cancer treatment is where it will make the biggest impact, or do you think that other diseases and conditions are as likely to benefit; and do you feel that researchers should concentrate on one disease first?

Dr Markman: While other groups of illnesses will clearly benefit from the revolutionary advances in our understanding of the molecular basis of health and disease, it is likely it will be in cancer where the impact on clinical outcomes will initially be most evident. This is due to the fact that we are most commonly examining actual abnormalities in genes when we are dealing with cancer rather than the likely far more complex issue of understanding clinically relevant variations in normal human polymorphisms when we attempt to modify outcomes in other illnesses.

I see no reason for researchers to focus on only a single disease, or a single cancer, as it is largely unknown where the next clinically relevant observation will be made that will favorably affect a health-related outcome.


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