So a few ‘casts ago I took issue with some of Chad’s “internet of things” podcast because I was skeptical that it was really going to change our lives. I understand that there are some cool gadgets that we can connect to the internet and get some fun automation for our homes, but I couldn’t get over that the internet of things was ‘transformative.’ So I was grappling with this a little bit and then heard a podcast on my all-time favorite ‘econtalk’ about the internet of medical things. In this podcast, Russ Roberts interviews Eric Topol who wrote the book ‘The Patient Will See You Now’ About how the medical world is about to undergo a drastic upheaval thanks to technology, the internet, and our devices.
I was so excited by some of the stuff they were talking about that I bought the book and got about 40% through it. I wish I could have actually finished it, but there was enough packed into that first 40% that I think we can start a really good discussion. What really struck me as I read through that first bit was how much I wanted to talk to Chad and Geo about it, because we have a REALLY unique perspective here at GG2K of 2 young guys that have grown up with technology that are in the medical profession. We’ll probably get into this a little more as we go on, but the average age of a doctor right now, is 55. For listeners that don’t know, Chad is a psychiatrist, and Geo is a genetic counselor, which has some SUPER exciting things to talk about. So I’m SORT of going to play the role of a stupid prompter, go over some of the main points from Topol’s book, and have you guys react to them.
So as a side-bar, I want to call out that one of the things I love about all of the Good Guys, and one of the true hallmarks of a good guy to know, is to be aware of your own biases. I’m going to talk about some stuff this episode, that, honestly, if you take them to the extreme, means that their jobs are going to look VERY different in the future. And a lot of people would be very threatened and defensive about that. My ‘guess’ is that Chad and Geo will not have this knee-jerk reaction, but I could be wrong so stay tuned.
So what is ‘the democratization’ of medicine? What do you guys think that means? Topol uses ‘democratization’ to mean “to make something available to all people.” He mainly is talking about data here. Now here we have yet ANOTHER good guy to know connection, because Perek knows a TON about medical data and all the challenges it presents so he may have some thoughts. But the main point that Topol drives home (for quite awhile), is that the content and flow of our medical data should be controlled and accessible for US. Up until the last couple years, and still in most cases, all of your medical data are controlled by the doctor. You go to a checkup, maybe get some labs run – if you’re lucky, you get the results in the mail – but most likely it’s a phone call and they say ‘everything’s normal’ and that’s the end of it. Want to take a stab at how many patients out of 10 in the united states actually email back and forth with their doctor? 1/10.
Now things are changing because there is a ton of medical data being generated by US, on our devices – and Topol only expects this to increase. We’ll get to examples of specific technology in a minute, but for now, suffice to say, it’s not just labs that can produce the data, it’s US. And once we have that data, it’s up to us what to do with it.
As with a lot of things in the technology age, the devices are cool, but their real power is unleashed when they connect to the internet. Topol argues that we are soon going to have an army of smart, hyper-connected consumers of health care that is really going to challenge the traditional – what he terms ‘paternalistic’ medical establishment.
Part of what Topol suggests we are doing as we are creating all of this data on our own, is creating a more complete picture of our health based on a ton of ‘omes.’ I’m not going to attempt to do all of them, but want to focus on two – the physiome (stuff we can measure with sensors) and the genome.
So things that can measure the physiome: Topol spends a good portion of the book talking about different devices that can be hooked up to smart phones to generate data. Some are just native that come with every smart phone, but some of the fancier ones are actually separate devices. Let me read an excerpt of what’s out there for ‘bio-sensors’ right now.
There are now wearable wireless sensors either commercially available or in clinical development, to capture physiologic data on a smartphone. This includes blood pressure, heart rhythm, respiratory rate, oxygen concentration in the blood, heart rate variability, cardiac output and stroke volume, galvanic skin response, body temp, eye pressure, blood glucose, brain waves, intracranial pressure, muscle movements and many other metrics. The microphone of the smartphone can be used to quantify components of lung function and analyze one’s voice to gauge mood or make the diagnosis of Parkinson’s or schizophrenia. One’s breath can be digitized to measure a large number of compounds, such as nitric oxide or organic chemicals, which could enable smartphones to track lung function or diagnose certain cancers.
I think a year or two ago, I would have said that people are never going to want to wear sensors all the time that constantly are tracking their health – but how many people do you see walking around these days wearing a fitbit to track their steps and heart rate etc. People are going to be doing this stuff.
Where it starts to get scary powerful, is when you combine some of this physiome stuff with the genome. Now we’ve done some podcasts on genome sequencing, but Geo, since you do this for a living, can you give us a 60 second explanation of what our genome is, and then a 60 second treatment of how accessible our genome is to us today versus let’s say 10 years ago when we were in college?
Cost for sequencing an entire genome was $28.8M in 2004 – is now less than $1500.
So there are a few big wins here – one that most people are super interested right now, is am I more susceptible than the general population for certain diseases/cancers, and is there anything I can do about that if I am? He spends a lot of time talking about Angelina Jolie and her choice to have both breasts and most recently, her ovaries removed.
The other one that we may have talked about before, but I had forgotten until reading this book is Pharmacogenomics. To keep this one really high level, this is tailoring the drugs you take to your specific genetic profile on how you respond to it. This is the type of thing where people are going to look back on it, and not believe that doctors just always prescribed the same thing to everyone of certain ailments.
Topol goes on and on about this stuff, but for now, let’s just stop with those two, and imagine some of the pieces of this puzzle fitting together. Maybe a person learns via their cheap genome sequencing that they are at higher risk for developing asthma. So they get a device they can monitor their breathing and have their smartphone alert them pre-emptively when they are going to have an attack, so go find an inhaler BEFORE they feel the symptoms etc. This is a really crude example but is stuff that we are months, not years away from.
He also talks about handheld ultrasound devices, and I wanted to ask Chad about this because of the following excerpt:
Availability of this technology has lead to at least two medical schools in the united states providing a device, instead of the traditional stethoscope, to all of its students on the first day. One health system in Minnesota has recently completed training its primary care physicians with handheld devices to conduct head-to-toe ultrasound physical examinations.
So let’s talk about a few more technologies that are here:
- How long do you think the average NEW consultation with a doctor lasts? 12 minutes (Repeat visits are 7 minutes)
- How long is the wait time? (62 minutes)
- Health Partners (A Minnesota company) has started to roll our virtual visits. This is happening now – where a user logs in, fills out some surveys, and gets a diagnosis and sometimes a prescription. This is an extension of minute clinics that have become super popular, and Topol sees no reason that this will extend to more and more doctor visits as time goes by.
- There’s an app called First Opinion that actually leaves you anonymous but also keeps you with the same doctor. (Since it’s anonymous, it gets around a lot of HIPAA regulations)
- Finally there are two companies called Medicast and Pager that offer doctors on demand 24/7. This is Uber for health care.
So one last thing that I ran across that I really wanted to get Chad’s/Geo’ opinion on that I read. As I was reading about all of these sensors, lab-on-a-chip, apps that allow you to text back and forth with a doctor, etc, I was thinking the whole time, ‘Well at least Chad’s gonna be safe, he’s a psychiatrist – his whole jam is talking to people and figuring out what’s wrong with them based on how they act, symptoms that aren’t physical. He has to ask questions based on hunches, and figure out more of a mystery.’ Then I read this:
Add to that psychiatrists who read an article in The Economist that a virtual shrink may be better than a real one, reviewing a study that showed that patients are more apt to confide and be open and honest with a computer avatar than with a counselor.
And Geo – one last excerpt for you to react to regarding tele-consultations:
A randomized trial was undertaken of 669 women receiving new data on their BRCA gene mutations who were assigned to either an in-person or telephone consult. Extensive evaluation after the information was reviewed showed that telephone consults were just as effective. With less than three thousand genetic counselors for a population in the United States of 330 million, surely this is good news for fixing the incongruous mismatch between the supply of this expertise and its increasing demand.
So I fully admit that this pillar may have gotten a little frenetic, probably because I haven’t yet finished the book and had a ton of time to digest its implications – but I just had to talk with you guys about some of this and get your thoughts from the inside on how realistic this really is. I personally can’t wait to try an online physical or something instead of going into the doctor.