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(Note: This commentary was co-written with Dr. Dennis Ausiello, the Physician-in-Chief of MGH in Boston and the co-founder [with me] of the Harvard PASTEUR program, a translational research training program initiated in 1999. He is also a member of the Board of Directors of Pfizer. As always, the views expressed in this piece are the authors’ own.)
“You can’t improve what you don’t measure,” first-year MBA students are taught. Yet physicians struggle every day to take care of patients based on remarkably sparse information, a nearly impossible task that has frustrated doctors and patients, and raised healthcare costs for everyone. It doesn’t have to be this way-but change will require a more deliberate focus on the real-world patients we’re trying to treat.
“A key challenge of the new medicine will be coming up with techniques that are not only minimally invasive, but also minimally intrusive.”–David Shaywitz, M.D.
When you think about great biomedical advances of the modern age, you think of our profound advances in molecular understanding–the precise analysis of DNA, for example, or the study of stem cell biology. The progress we’ve made in taking science from the patient’s bedside to the laboratory bench has been nothing short of exceptional. The problem is that we’ve had a lot more trouble moving in the other direction: returning science to patients, and translating laboratory results into clinical progress.
We’ve had a particularly hard time with the final and most important step in research translation–the gap between the clinical practice of medicine and health as it’s experienced in real life, every day, by real people. It has become increasingly clear that the next great wave of innovation in medicine will-must–revolve around this gap and how to close it.
Consider your last visit to a doctor-if you can remember that far back. Most likely, your physician took a hurried history, performed a brief physical exam, and perhaps requested several laboratory tests or an imaging study. You may then have been given some advice, likely a prescription as well, and then you are gone, lost to the system until you decide–or need–to return again.
Even if your doctor is an expert diagnostician, and ordered just the right tests, how much did she really learn about you and your health, about how your body and mind were doing during the time since your previous visit? Even she made treatment recommendations informed by the robust clinical studies, does she know how closely you’ve chosen to follow her advice, or what other activities, behavior, or habits you may have adopted that could be influencing your health?
The limited visibility your physician has into your health has implications for her as well as for you. Without a functional feedback loop, without a way of reliably connecting what she is doing in the office with the results-improved health-she is trying to achieve, she is effectively flying blind. She has no way of figuring out the right interventions for you and other patients, and no way to learn what she’s doing particularly well and where she might improve.
This has profound implications for our healthcare system as well: with so much of our GDP devoted to healthcare costs, it’s important to figure out how to deliver care-as measured by improvements in the real health of real patients–as effectively as possible, and to ensure that doctors are using the most effective treatment approaches for each patient seen.
Solving these problems will require investment in a concept we call “continuity-inspired medicine” (CIM), an approach to medical research and practice that aims to be closer to the patient in both space and time, and will be built on a foundation of more personalized measurement.
“Measure something,” legendary endocrinologist Fuller Albright would admonish his students. As usual, Dr. Albright was onto something: measurement matters, and it’s essential that we develop improved approaches that will provide a much fuller understanding of patients in their daily lives, including technologies that can monitor a range of physiological factors, such as blood pressure, oxygen saturation, and glucose level, as well as many other factors we’re just starting to contemplate.
We will also need to develop robust approaches that can meaningfully assess psychological well-being and quality of life, and to capture more completely the behaviors that can impact health, including diet and activity level, prescription adherence and subtle habits.
Here’s the catch: while everyone wants to be healthy, most of us don’t want to spend our time thinking about our health, measuring our health, reporting our health; a key challenge of the new medicine will be coming up with techniques that are not only minimally invasive, but also minimally intrusive. This is a difficult but not impossible task: early examples of this approach include pill bottles that automatically report when they’ve been opened and activity monitoring using smart phones.
Improvements in measurement (imagine months worth of data summarized on a simple dashboard) will enable providers to understand with much greater precision and nuance the effects of their recommendations and to see what sorts of approaches work best for each patient-the opportunity to personalize therapy based on a patient’s distinctive physiological and behavioral characteristics as well as their unique DNA. Better measurements-together with improved, accessible data registries–will also enable the sort of progressive, incremental improvement in health delivery that is nearly impossible without a functional feedback system.
The evolution towards more personalized measurement will also have implications for the private sector, creating exciting opportunities for the entrepreneurs and companies who will develop these novel technologies, methods, and data management systems. A more detailed view of existing medical need will also enable drug and device companies to sharpen their focus, and to develop products in a more efficient and effective fashion.
Creating the personalized healthcare system of the future will require the combined efforts of universities and industry, regulators and entrepreneurs. But more than anything else, it will require an unprecedented level of participation from patients themselves, whose willingness to contribute to this effort and share of themselves will ultimately drive the success of this initiative.
A decade ago, it would have been difficult to imagine such a level of patient participation. But in the era of Facebook, we now understand that not only is possible for medicine to move closer to patient, but patients will increasingly expect it, and demand it.
As usual, it will be our patients who are teaching us-and our responsibility to ensure we are listening.
For further reading:
Ausiello & Shaywitz, “Back to the future: medicine and our genes” (NYT)
Ausiello & Shaywitz, “A gap between lab results and lives saved” (Boston Globe, abstract only)
Shaywitz & Cairns-Smith, “The Behavior Gap” (Forbes.com)
Ausiello, “Science education and communication” (JCI)
Shaywitz & Mammen, “The next killer app” (Boston Globe)
David Shaywitz, MD in an Adjunct Scholar at the AEI; Dennis Ausiello, MD is Physician-in-Chief of Massachusetts General Hospital, and a member of the Board of Directors of Pfizer.
Improving healthcare will require increased focus on the gap between the clinical practice of medicine and health as it’s experienced in real life.
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