By Eric Topol, MD. New York: Basic Books, 2015. ISBN 978-0-465-05474-9. Hardback, 364 pages. $32.
You may already be familiar with this book but, if not, I urge you to become so. Particularly if you, like me, are over the age of 30. Eric Topol is an American cardiologist, a professor of genomics and, as his book thoroughly demonstrates, someone who is completely comfortable with the sweeping digital revolution that is happening in medicine right now. He also has a Twitter account worth following.
The book is divided into three sections. The first section deals with the issue of who is in charge of health care information. Here Topol comes down firmly on the side of the patient. He rails against what he characterizes as the paternalistic attitudes of the medical establishment, both historically and in the present. Topol feels strongly that we are living in a new era where increased access to information about one’s health can lead to individual empowerment regarding health care choices.
I found Topol’s extensive coverage in this section on 23andMe, the consumer genomics company, and its personal genome service (PGS) interesting and helpful. 23and Me has been receiving considerable coverage in the popular press recently. At the moment an unusual situation exists in that the health-related results revealed in 23andMe’s PGS are available to Canadians but not to Americans. Topol covers in detail the decision by the FDA to ban 23andMe from offering this information to Americans and the reaction to this decision. Anyone interested in learning more about 23andMe testing should go to the company’s website and review their terms of service. It has yet to happen to me, but I’m sure it won’t be long before I see someone with their report from 23andMe asking me what it means that they are positive for some health-related genetic marker or another. In the end Topol characterizes 23andMe as a starter kit but does feel the report on drug interactions is worth learning about, a suggestion that prompted me to order a 23andMe kit for myself.
The second section deals with all the health data, both macroscopic and microscopic (genomes, microbiome, etc.), that are available for analysis and the myriad, and rapidly growing, ways this information can be collected and stored. Topol writes extensively on the role of genomes in medicine. To further illustrate the accelerating importance of genomes, to both patients and the cancers from which those patients suffer, recently NEJM Journal Watch carried a story about the rise of so-called basket studies. In these studies patients are enrolled not on the basis of the particular type of cancer from which they suffer but on whether their cancers share particular mutations. One such study involved patients with various types of histiocytosis. They received a melanoma drug that targets a particular BRAF mutation, and initial results were very encouraging.
Also in the second section, Topol derides the use of the traditional stethoscope and favors the use of a pocket ultrasound device that can image various organs. He makes reference to, but does not name, two American medical schools that equip their students with such a device on their first day. He also decries the current state of EMRs because of their lack of portability and universality and feels that the way they are currently used acts as a barrier to establishing a personal connection between the physician and the patient, a barrier that could be removed with the development of speech-to-hardcopy systems.
Topol returns again and again to the theme of patient autonomy in the matter of ownership of data. A simple example that comes to my mind is the review many of us do of the collection of outpatient blood pressure readings that we ask our patients with hypertension to record at their local pharmacy. This section also introduces the revolution in personal and world medicine that the use of smartphones is engendering, such as the use of “obsolete” smartphones in the delivery of health care in developing countries.
The third section of Topol’s book deals with the impact that the previously described changes are having and will have on the way health care will be delivered. In essence, this comes down to the old categories of who, how, where, and when. The category of who will collect data and who will deliver health care is expanded far beyond us physicians. Under the category of what, again Topol has an extensive section on what he sees as the role of smartphones. A development not touched upon in Topol’s book is Apple’s recently announced ResearchKit software, which expands the ability of iPhones to become diagnostic and research tools. As I understand it, one of the aims of initial ResearchKit apps is to broaden the potential pool of study subjects by making it easier to recruit participants. One app, mPower, which is involved in research on Parkinson disease, uses readings from the accelerometer, microphone, gyroscope, and GPS sensors to gather data on an individual study subject. Patient confidentiality remains a concern.
I have only a few caveats about the book. Topol’s analysis deals with the American medical system and American society’s emphasis on individual freedoms, though many of his observations and conclusions can be transferred to our Canadian system. Another issue is the lack of emphasis he puts on the for-profit factor that comes with the principle of bringing more autonomy to patients regarding their health, an aspect of the case dealing with private surgical clinics currently before the Supreme Court of Canada that, in my opinion, is too little commented on. He also doesn’t deal with the issue of whether the increasing availability and use of patient-generated data will lead to further burdening of our already-strained publicly funded resources.
In the end Topol convinced me that perhaps the stethoscope is on its way to join the slide rule as a reasonably useful but ultimately limited analog instrument. I remember the response one of my first medical school professors, also a cardiologist, gave to the question of whether we would be better off using a Littmann or a Sprague-Rappaport stethoscope: “Remember this, young doctors, it is not so important what you put into your ears, but what is between them.” I believe the crux of the matter is not so much how we as physicians obtain data on our patients’ health, but how we counsel and advise our patients on what to do with the results of that data.
—Doug Cooper, MD
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