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20171217 – Patient will see you now

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MAIN IDEA:

The main idea of this book is that contemporary medicine is not capable to keep up with technological developments and is bound to be substituted by the new medicine that will be not only patient centric, but also patient controlled and directed with the technology providing all necessary support via access to information, data collection devices that patient can use, and doctors relegated from CEO of treatment to highly qualified supporting specialist who would take over only if patient is mentally incapacitated.

DETAILS:

Section 1: Readiness for a Revolution

  1. MEDICINE TURNED UPSIDE DOWN

It starts with the discussion of old phenomenon of the “difficult patient”, the one who does not trust doctor without questions and trying to get access to medical information and even participate in decision-making relevant for them. Author makes point that with Internet and access to all kind of medical devices from blood pressure measuring machines to portable EKG patients can and do produce their own medical information and analysis based on Internet medical websites. After that author discusses his own experience with portable devices and concludes that they do bring qualitative change in access to collection of information together with increased levels of education led to rise of smart patients.

  1. EMINENCE-BASED MEDICINE

This is a look back at traditional medicine when doctor was practically the only entity with access to data and final decision maker, whose decision was not to be challenged, except by other doctors. In addition to looking at this historical situation author brings a personal story about his grandparents who were not well served by the medicine of 1960s. Moreover, he applies it not only to some individual doctors, but to overall condition of medical knowledge, which as any other knowledge, when start moving to scientific method is continuously developing and changing, in process removing or at least dramatically decreasing medical authority. Author provides a nice table of medical tests that proved to be inadequate, meaningless, or even harmful in the view of newly acquired data:

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  1. A PRECEDENT FOR MOMENTOUS CHANGE

Here author discusses impact of the new technology such as smart phone combined with Internet and compares it with the previous revolutionary change in information technology: Printing press. Here a couple of graph he provides to demonstrate consequences of such information revolution:Screen Shot 2017-12-17 at 8.30.52 AMScreen Shot 2017-12-17 at 8.31.00 AM

  1. ANGELINA JOLIE: MY CHOICE

Here author moves to our time providing quite a dramatic result of individual making very challenging decisions about her health based on her understanding of scientific information specific for her not only current, but also probable future medical condition. Since this individual is very famous, rich, and is subject of admiration by millions of people, her very public decision-making had a significant impact on the huge number of people, medical industry, and market for genetic analysis.

Section Two: The New Data and Information

  1. My GIS

This chapter starts with comparison of human body with Geographic Information System (GIS), which provides multiple layers of data about environment. Author believes that similarly to GIS it is possible to combine multiple layers of data about a person that would allow prevent and/or quickly react to any deviation from optimal health conditions. Here is a nice picture of all these layers, which follows by brief explanation of each layer:

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Social Graph and the Phenome: It is about individual within his/her social environment.

Sensors and Physiome: Biosensors collecting all kinds of health-related information from heart activity to blood pressure, mood and everything in between.

Imaging and Anatome: This layer includes more complex and expensive scanning: MRI, CT, X-Rays, and other methods to evaluate person’s anatomy at any given moment in time.

Sequencing and Genome: Personal DNA analysis

The Transcriptome: This is about transfer of information from DNA to RNA and correspondingly expression of genes, which turned out to be a complex and important process in its own right.

The Proteome and Metabolome: This analysis of body proteins, autoantibodies, and metaboles – compounds resulting from body’s metabolism

The Microbiome: This is an analysis of all other organisms that are included into our body, but have different DNA than our own: bacteria, viruses, fungi, and what not. Interestingly enough, it represents at least equal amounts of human and non-human content.

The Epigenome: The side chains and packaging of our DNA. This staff can actually change genes expression causing all kinds of problems. It is cell specific and can be decoded similarly to DNA.

The Exposome: This is about our environment with all nice things like radiation and pollution exposure to which could be tracked and analyzed as a factor in condition of body.

All together these areas of analysis could provide information for pre-womb to coffin health maintenance that author envisions in such way:

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Author discusses in some detail how it could work for a couple of examples, specifically how it would apply to cancer:

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  1. MY LAB TESTS AND SCANS

This starts as somewhat panegyric to Theranos, which is currently not in such a great shape, but main point is still valid: patients should have unlimited access to all testing results relevant for them. Moreover, the emerging technology promises lab on the smart phone when various attachments allow measuring all kinds of electrical, mechanical, and chemical signals produced by a body. Another emerging technology: Lab in the Body: that is imbedding sensors into human body to analyze all kinds of processes occurred in there without sending any external signals in any form. Author also discusses side effects of multiple scans and necessity to use these scans wisely. The final part of the chapter is about miniaturization of scanning and possibility of pocket MRI linked to one’s smartphone.

  1. MY RECORDS AND MEDS

This chapter is about medical records, needs for their transparency to patient and to doctor. It actually becoming critical because of the huge amount of powerful medicines that interact in extremely complex way very much outside of human ability to trace and understand it.

  1. My Costs

Here author discusses costs, as usual pointing out to contrast between costs in USA and elsewhere. Here is a nice breakdown for this issue:

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Obviously there is a lot that could be improved by making prices transparant and removing diconnect between payor and user of medical services. Obviously it is mainly separate and huge issue.

  1. MY (Smartphone) Doctor

This is about access to medical knowledge that is changing dramatically with advance of medical websites that help to establish diagnosis, develop treatment plan and do all kinds of things that before required doctor’s full involvement. An interesting result is the decrease in number of physician visits by 17% despite aging of population. It coincides with improvement in outcomes. Another point is that increasingly challenging environment for doctors leads to decrease in their numbers and availability. Here is a nice picture of multiple factors impacting them:

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Section Three: The Impact

  1. THE EDIFICE COMPLEX

This is about hospital stay and need to move treatment as much as possible to outpatient care or even to patient’s home. Author recalls his experience as young cardiologist when even simple procedures required long hospital stays, contrasting it with much shorter stays now. Author discusses hospital of the future, which goes far away from simple bed to complex technologically heavy site that provides constant monitoring of patients, protection against infection and external interferences. But most promising development is advance of technology that could make hospital if not completely eliminated, then reduced to emergency use only.

  1. Open Sesame

What author here wants to open is access to medical data so he starts with reference to open source software and the proceeds to discuss Massive Open Online Courses (MOOC) that allow learning without attending expensive classes, and finally renames them into MOOM, where the last letter stands for “Medicine”. He looks in details at cancer specific MOOM and then discusses information flows and role of government in opening access.

  1. SECURE vs. CURE

This is discussion on privacy and its increasing disappearance in all areas including personal medical data including genetical information. At the end author expresses his believe that all medical data about person should be owned by this persona and hope that it would help with privacy issues.

  1. PREDICTING AND PREEMPTING DISEASE

This is about changing the whole approach to medicine from mainly reactive process to proactive when service delivered not in response to complain, but rather continuously on regular bases with stress on preemption of disease rather than treating it when symptoms become obvious. Here is a nice diagram demonstrating author expectation for future changes in life expectancy resulting from this:

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  1. FLATTENING THE EARTH

This is about globalization of medicine both in term of collecting data and providing services across borders. It goes through usual trope of need to help poor countries, development of cheap substitutes for technology and medicines, but most interesting are a couple of graphs that demonstrate that overall deaths due to infections and other diseases of the poor actually fall way below deaths from the same diseases that rich people die from:

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  1. THE EMANCIPATED CONSUMER

The final chapter is kind of summery with the stress on the main point of this book: switch to patient directed medical services based on technology with doctors involved mainly in consulting roles and high complexity specialty service. Here are two pictures presenting this vision:

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EPILOGUE

This is pretty much list of references to various forms of what author calls iMedicine Galaxy starting with smartphone:

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This also includes various imagining technology that allow scanning of one’s own internal organs condition and other digital appliances. Author completes it with graph for overall medical data transfer and processing:

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MY TAKE ON IT:

I think this is a wonderful book with lots of good ideas and, very important, lots of information about technology available now for anybody who wants to be in control of his/her own health. I am pretty sure that direction of development that author describes in this book is not only valid, but practically inevitable. I would only add that, in my opinion, author a bit underestimate value of personal relationship that could potentially develop between individual providing health service and patient. With all these new devices, information processing, and soon coming fully developed AI the role of healer will change. It would stop being mainly technical processing, when doctor really does not know patient as human being and mainly treats this patient as body, not that different from mechanic treating car in repair shop. It would become more friendship like continuing relationship with specific goal to provide psychological, technological, and informational support from a person dedicated to such support for just a few or maybe a few dozens people. It would be probably mainly something like regular monthly meeting with discussion of individual about mental and physical health based on recommendation of AI developed with use of readings from multitude of scanning devices constantly monitoring individual’s condition. I guess it would require completely different skillset much less related to butchery than it used to be in the past and is still prevalent in present.


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