1. Dr. iPhone: How Will the Smartphone Physical Change Healthcare?

    One of the much-hyped features of this year’s TEDMED conference ws the “Smartphone Physical” — a physical assessment conducted entirely through mobile health applications. Here’s the video, courtesy of Medgadget:

    My first interaction with a cellphone app was in 1999; it was the snake game on a non-color, low-res flip phone. I laugh to think that, at the time, it mesmerized me as much as this does now. In 15 years, we’ve transformed the mobile phone from a mere communication device to a 24/7 interface that lends context, connectivity, and quantification to our every action.

    Mobile health applications represent the next stage of patient empowerment. 30 years ago, patients received information and procedures from their physicians, often without instruction. Now, the smartphone physical empowers patients to identify, understand, and manage their own health on a completely new level. This offers critical implications for the future of medicine:

    1. Patient Engagement: It’s probable that the physical act of regularly checking blood pressure or measuring blood sugar levels can make a patient more conscious about their health. It’s also hopeful that such self-tracking can inspire self-education and positive behavior change. This is difficult to measure experimentally (have you ever noticed that the most avid quantified self-ers are the fittest and healthiest people?) but it offers reason to be optimistic about mHealth.

    2. Remote Care: A critical challenge of hospital readmissions is that, once the patient walks out the door, it’s no easy endeavor to reconnect with them. If physicians could remotely monitor patients, it’s possible they could identify early signs of a complication and intervene. As a readmissions researcher, I’ve spoken with patients who waited for three weeks of not being able to eat before returning to the hospital 30 pounds lighter. The smartphone physical could have flagged that—and someday, it will.

    3. The Doctor’s Role: This is the big question, and it’s a loaded one. How will physicians interpret and process the information overload that follows such complete self-quantification? How will electronic health records and/or personal health records adapt to meaningfully consolidate, analyze, and present all this data? How does the patient’s ability to self-educate, self-diagnose, and (perhaps eventually) self-treat change the purpose and significance of the doctor-patient relationship? At Millennial Medicine, Dr. Eric Topol presented these mHealth innovations and said, “With this, why would you want to go to the hospital?” Good question — Will patients still want, or need, to interact with their doctors?

    These are ambitious goals, but with the advances I’ve seen in this video as well as other seminal achievements made in mHealth and digital medicine recently, I’m optimistic that they are all entirely doable. I’m also conscious of how often I’ve used the word “possible” in this reflection and how scarcely I’ve said “proven.” It simply speaks to the fact that we’re faced with inspiring technical capabilities that offer tremendous hope; the challenge now falls to tomorrow’s physicians and scholars to innovate, research, and troubleshoot to bring these ambitions to realization.

  2. Millennial Medicine: Recaps, Reflections, and Insights

    College is a unique opportunity to learn from the innovation, genius, and vision of leading thinkers. Today, I had the opportunity to participate in transformative dialogue on the future of medicine at Millennial Medicine 2013. The symposium was centered on one premise: What will medicine be like in future generations, and how can we mobilize upcoming generations of physicians and scholars to get there? 

    Today’s speakers were captivating, inspiring, and wildly thought-provoking. After listening to them, I’m both incredibly empowered by the opportunities and overwhelmed by the vast range of options in the future of medicine. Here, I offer some of my key takeaways from today’s conversation.

    Eric Topol: Big Data and Personalized Medicine

    Everyone is a living data bank: a summation of biometric data, actions, preferences, and thoughts. Before the crowd, Dr. Eric Topol showed how his phone could monitor cardiac rhythms, check blood glucose levels, and measure blood pressure. Dr. Topol predicted that patient access to data—mobile health, digital media, and patient-facing health records—would produce a new paradigm of healthcare where patients could identify and manage their own health conditions.

    While I believe that digitization of human beings might eventually hold great promise for personalized medicine, I’m still skeptical of big data’s relevance in medicine. Doctors simply don’t have the time, interface, or processing technologies to analyze such large volumes of data. We’ll get there eventually, but we need advances in biomedical research, bioinformatics, and natural language processing that just aren’t there yet.

    Marc Triola: Digital Platforms for Massive Open Online Medicine

    Dr. Marc Triola, an educational informatician at NYU, presented the NYU Virtual Microscope: a ‘Google Map’ of histology where students can study digital replications, share comments and conversation on physiological “points of interest,” and compare graphic renditions of functional and diseased tissue. NYU integrates the digital interface with the anatomy lab; students learn and interact with the Virtual Microscope, then move to the cadaver for a hands-on approach.

    The NYU approach captures the best elements of MOOCs and brick-and-mortar institutions. Like MOOCs, students can study independently, work at their own pace, and engage the material outside of the classroom. Still, the social interaction component and the cadaver lab segment of the curriculum recognize that teaching needs to be hands-on and that learning occurs best when the experience is shared with others. I’ve been skeptical of Coursera and EdX for this, but I think NYU Med’s “flipped cadaver lab” showcases the future of education.

    Anne Balsamo: Patient Engagement Through Digital Media

    Dr. Anne Balsamo presented a fascinating arrangement of historical and emotional value: a digital, fully-indexed chronicle of the AIDS quilt. After a morning filled with a data/analytics approach to future medicine, Dr. Balsamo’s humanistic representation of the AIDS epidemic was visually stunning, emotionally compelling, and educationally engaging.

    I was so moved by the Digital Quilt Touch application that I wonder: Might digital media offer an opportunity to engage patients? What if it wasn’t an AIDS quilt application, but a patient-facing educational platform? What if digital design could teach patients about their illnesses? What if app interfaces could educate patients on self-care and symptom management? Digital design catches the eye, then hooks the mind and heart. By engaging patients, digital technologies can give them the motivation and resources to better navigate their illness and the healthcare system.

    Jay Baruch: The Physician as a Listener

    The EM environment has a reputation for being a high-stress, high-acuity, high-volume climate: in short, not the best setting to cultivate human relationships. Yet that’s exactly how Dr. Jay Baruch described his profession: as a listener of patients’ narratives of illness. Dr. Baruch presented an alternate dimension of emergency medicine, with an emphasis on listening, empathizing, and engaging. In a sharp contrast with Dr. Topol’s ‘smartphone physical,’ Dr. Baruch cautioned, “We can’t jump to technology without prudent attention to the patient’s story.”

    As an EMT, a medical sociology researcher, and an aspiring emergency medicine physician, Dr. Baruch’s presentation was deeply personal. In medicine, I am most captivated by the beauty of the physician-patient relationship. Medicine is fundamentally an art of storytelling and story elicitation. As a researcher of hospital readmissions, I interview readmitted patients daily about the gaps in their discharge and care handoffs. So often, it is a missed clinical finding, a communication error, or an oversight of a social barrier to self-care: in short, outcomes are impaired because the narrative is not fully appreciated. Though it’s hard to fault doctors for this; I suspect more physicians would stop and listen closely to their patients if the time and compensation procedures in medicine were more forgiving.

  3. Patients€™ Genes Seen as Future of Cancer Care →

    Hospitals are spending heavily to develop €œprecision medicine€ treatments for cancer based on the special, even unique characteristics of the patient’€™s genes.

    It’s finals period here at Rice, so I’ll keep the updates minimal for this week. Still, I wanted to pass on this article about the increasing role of gene sequencing in disease screening, diagnosis, and treatment, and to offer a few thoughts of my own.

    1. Bioinformatics in Clinical Practice: In order to implement genetics testing and personalized medicine en masse, physicians need a way to screen large volumes of data in short periods of time. For this, there has to be a way to integrate gene-sequencing data into patient health records. There also has to be a built-in alert system or smart-bioinformatics component that alerts the physician to possible polymorphisms that signal a genetic basis for disease. Without these advancements, bioinformatics-centered medicine will fail to penetrate standard clinical practice.

    2. Maintaining a Holistic Worldview: It’s important to bear in mind that genetics is not the final answer in disease etiology and management. Medical conditions are shaped by not only genes, but also social contexts, environmental exposures, and health behaviors. Moreover, genes themselves do not tell the whole biological story; also critical is epigenetics, or the study of gene expression changes that are caused by non-base pair determinants like methylation and acetylation, which effectively “turn on” and “turn off” genes. Epigenetics is a dynamic process over time, and it can be influenced (and influence) the previously mentioned macrosocial factors of disease. Essentially, the bottom line here is that disease is much more complex than genetic programming, which is important for laypersons to understand when hearing about these advances in genomic medicine.

    3. Ethical Challenges in Genomics: The idea of a genetic vulnerability to disease raises all sorts of ethical challenges that are difficult to resolve. For example, if an individual has a genetic basis for disease, to what degree that absolve him/her from responsibility for that condition? More problematic is the challenge of genetic vulnerability for psychiatric disorders. There are genetic polymorphisms that underlie a genetic susceptibility to traits like impulsivity, risk-taking, depression, or aggression, and these traits are frequently found retrospectively in criminals. How do we treat someone who has the genetic predispositions of a societal risk? Do we place precautions or limitations on that individual to minimize potential for dangerous incidents? By knowing that a threat is possible, what responsibility do we have to act on that? It’s a very “Minority Report”-like paradigm.

    Just wanted to throw those out there. It’s been a bit of a hectic week, but blogging is a necessary respite from the finals grind!

  4. Corporate Sociology and Understanding the Patient

    Fast Company had a great profile yesterday on Andy Santamaria. Andy works for Square—Jack Dorsey’s mobile credit card reader application. As the startup’s “Small Business Research Lead,” Andy’s job is to interact with the vendors that use Square, to understand their stories, and to incorporate their narratives into improving the Square user experience.

    Stated otherwise, Andy is essentially a corporate sociologist. The fact that his job even exists is telling; it speaks to Square’s responsiveness to consumer needs and the commitment to tailoring the firm’s goals and priorities to align with the user’s.

    The story of Andy and his work with Square is intriguing, because it offers a sharp contrast to the customer service philosophy (or apparent lack thereof) in medicine.

    How well does medicine design its interface to meet the patient’s needs?

    For even the well-educated, navigating the illness experience is a challenge. While care providers gather much information and conduct many tests for each patient in a hospital, the patient’s ability to access that information is an uphill climb. The limited opportunities that patients have for face time with a physician are usually governed by an agenda of what the physician wants to obtain and ask, instead of what the patient wants to know. Even at discharge, the hospitals I have been to present patients with overwhelmingly-formatted paperwork with large blocks of text in minute-scale fonts and overly-technical language. In summation, to say the interface in medicine is patient-centered is a stretch, and anyone who has ever experienced the waiting, the uncertainty, and the confusion of hospitalization knows this well.

    How well do hospitals and healthcare providers understand the lived experiences of their patients?

    As a qualitative health services researcher, my role is to interview patients about their experience recovering from surgery at home. From this experience, I know too well how little care providers understand about the patient’s home experience. One study showed that physicians estimated patient retention of discharge instruction twice as high as measured by assessments of patient knowledge (~80% vs. 40%). If care providers understood the uncertainty of home recovery, the confusion of managing complex self-care instructions, or the frustration of treatment adherence for someone in a socioeconomically-disadvantaged situation, discharge planning and patient follow-up in this country would be radically different. If care providers took the time to understand their patients’ narratives, as Square does, I do not believe the national readmission rate would be 25-30% or that the treatment non-adherence rate would be near 75%.

    I should clarify that this is not a physician problem, but a structural problem. For a qualitative sociology project, I interviewed emergency physicians about the social and emotional connections they built with their patients. Universally, all physician respondents cited time constraints, long hours, high-acuity environment, and fee-for-service compensation structures as limitations to close physician-patient relationships.

    This makes sense. At Square, Andy’s entire job is to understand how his customers live and operate. Physicians have to manage that task while caring for a dozen other patients, documenting their care in the EMR, completing administrative responsibilities, teaching residents and medical students, and conducting scholarly research.

    Medicine’s current system is not set up to be responsive to patients. Providers have a limited, often-incomplete view of how their patients think, survive, and navigate illness. And it’s not their fault: that’s simply how the system is designed. But I predict that if medicine added a sociological component like Andy’s job, it’d vastly improve our ability to provide patient care that is more responsive to the realities of the sick.

  5. Be Prepared

    In the wake of a national tragedy like Boston, the immediate response is an urge to take action. As I saw the images of distressed onlookers, hurried first responders, and bloodied, debris-laden streets, I felt chained by the geographic divides that prevented me from being more than a digital bystander. The emergency responder in me felt the urge to do something, dampened with the realization that there was little a Houstonian could do to provide solace, comfort, or aid to those suffering from tragedy a time zone away.

    After a few minutes of reading panicked live-tweets, I paused. I turned off Tweetdeck, silenced my phone, and muted the Boston Fire/EMS radio channel. And I did the only thing I knew I could do in that situation: I read. I foraged the internet for EMS continuing education and FOAMed resources, and studied what I could find on blast injuries, medical triage, incident management, and ALS trauma protocols.

    As mechanical and unemotional as it may sound to respond to a human tragedy through self-education, Boston was a jarring reminder to the EMS community that you can never predict when shit will hit the fan. You will never have time to read up on a protocol or study a scenario when the tones drop; you have to always anticipate the worst and be ready to rise to the occasion. The ability to be prompt, calm, and responsible is an obligation we hold as first responders, and we owe it to the communities we serve to be ready for anything. The best support we can offer the public in the wake of a tragedy is the comfort that their public response systems are prepared to act.

    If you are a medical professional, the best thing you can do in the wake of a tragedy is to prepare yourself. 12 years ago, it was FDNY. Yesterday, it was Boston EMS. Tomorrow, it could be your service, and it’s absolutely critical to be ready for that.

  6. Big Data and Medical School Admissions

    A pair of articles from the Economist caught my eye this morning; the first is on firms’ growing use of psychometric testing for screening job applicants, and the second is on firms’ use of big data to identify traits that signal an applicant’s long-term quality. I’m interested in the potential to apply these concepts to medical education and the medical school application process.

    Right now, the medical school application process is all about forecasting.

    First, medical schools decide what characteristics they want in applicants: some look for research intuition, others look for an interest in primary care, and most screen for some combination of empathy, teamwork, communication, intelligence, and leadership.

    Next, medical schools obtain a range of rough quality measures from applicants: GPA, MCAT score, letters of recommendation, essays, and an interview. 

    The last part is the most complex: medical schools must use these quality measures to ascertain how ‘med-ready’ an applicant is, which is inevitably a challenge. How well does undergraduate GPA predict a future physician’s ability to develop clinical knowledge? How accurately does an interview answer or essay response indicate empathic capabilities? At best, the process is like forecasting the weather: you can get fairly good predictions, but even the best predictions are still reasonble hunches, at best.

    In the age of big data, however, there is huge potential for medical schools to identify data-driven predictors of successful medical careers. Think of it like “medical admissions sabermetrics”: by aggregating applicant data with longitudinal measures of clinical and academic achievement, medical schools can develop measures from which to more accurately vet future physicians. 

    Medical schools have already started implementing efforts at objectivity. Some schools have replaced traditional interviews with multiple-mini interviews (MMIs) to minimize interviewer bias in the selection process. More broadly, the MCAT 2015 redesign offers a more objective way for medical schools to measure proficiency in social aspects of medicine, a factor which was previously more difficult to quantify or evaluate. Why not go the extra step further and develop objective analytics to select candidates? If a school wants primary care physicians, it can use analytics to target students with traits of those who select into primary care. Likewise, if a school wants team-based practitioners, it can develop and validate psychometric surveys that correlate with future empathy, leadership, and cooperation.

    There’s a couple of potential issues here, of course. Schools have to come to a consensus on what to measure; what factors distinguish good doctors from bad ones? Schools need to prevent applicants from ‘gaming’ the system. And finally, schools have to ensure metric validity, which considers how well a measure actually evaluates what it thinks it is looking at. These are no easy tasks to overcome, but as a current applicant preparing to present myself to medical school admissions panels across the country, the idea of an objective, data-driven approach to admissions certainly has its appeal. 

  7. Why Would Anyone Choose to Become a Doctor? →

    Inevitably, the pre-medical curriculum is tiring, and daunting, and quite often exhausting. In a week that’s been terribly busy and exhausting, I turn to insights like this piece from Danielle Ofri, one of my favorite physician-writers, on why people choose to become doctors. At the end of the day, despite all the exhaustive tasks and struggles, there’s still the very unique doctor-patient relationship and the chance to foster a truly unique human connection—and that makes all the difference.

    With EMS, I would have to concur that the motivations to keep going and keep your head up are, indeed, much the same.

  8. Medical Apps: Where’s the Credibility?

    A few weeks ago, I wrote a critique post on the lack of outcomes research to justify use of quantified self devices like Jawbone, Fuelband, or Fitbit. This morning, an article in USA Today echoed my sentiments, expressing skepticism over the accuracy of sleep trackers. Eric Topol tweeted:


    To be fair, sleep trackers range in value from the $1.00     Sleep Cycle iPhone app to devices like the $200 Basis [links not endorsements], and it may not be appropriate to group them all together as non-credible. Still, the hype over such devices raises several important points:

    1. A need for outcomes research: Should health devices be able to market themselves as such without a RCT-proven benefit? Can we say for sure whether the process of quantifying oneself truly has health benefits in practice? Until the studies back the marketing, I’m holding off on buying any self-tracking wristband.

    2. A need for regulation: Traditionally, there are strict regulatory processes that govern the advertising and sale of medical devices and pharmaceutical therapies. These are vital for patient safety and credibility. Regulations prevent consumers from buying sketchy OTC diet pills with a potential for adverse health effects. Regulations also prevent manufacturers of such pills from marketing placebos or chemically ineffective treatments as valid medications. A similar type of signaling is imminently necessary as adoption of digital health apps and devices widens. This is why I remain unconvinced of arguments that digital health regulation is unnecessary and stifles innovation.

    3. A need for physician involvement: Physicians are an important source of credibility and advisory for patients, even in the age of patient empowerment. According to the Pew Mobile Health survey, half of patients who find information online then consult their physician about their findings. This is a strong indication that, even when digital health information is readily accessible, patients aren’t fully confident in their own ability to make sense of that information. In those moments of uncertainty, physicians are still the go-to bridge between patients, their diagnoses, and their data. Given the vast growth of mobile health, physicians can (and should) get involved with the innovation wave. In the near future, doctors should connect patients with the applications and devices that are best for them, effectively “prescribing apps”  the way they do medications. But of course, it’s difficult to encourage doctors to educate and bridge patients to mobile health innovations without the requisite outcomes data.

    Before the 20th century, healthcare was a space characterized by uncertainty, nonstandardization, and speculative experimentation. With much research and regulation, we can now trust in the credibility of our physicians, the procedures they perform, and the medications they prescribe. Digital health is currently a similar unrestrained frontier of speculative experimentation. We need to introduce outcomes, regulation, and expert advisory to ensure that these innovations translate to health benefits.

  9. Redefining the Doctor

    Vinod Khosla notably made the assertion that “technology would replace 80 percent of doctors.” I disagree; I don’t see technology making physicians redundant. Instead, I see technology redefining the role of the physician, changing the paradigms of how doctors process information, interact with patients, and treat diseases. Here are a few resources that illustrate the way that digital medicine, the empowered patient, and health IT are remaking the doctor’s role.

    Sunrise Rounds: “The Doctor Will Teach You Now”
    Historically, the roles of ‘doctor’ and ‘teacher’ have been closely intertwined in medicine. Forces like quantified self and online health information are eroding traditional models of physician-centered health decision making by putting data in the patients’ hands. When Dr. Topol’s “Show me the data!” vision is realized, doctors will shift back into the educator role, providing the knowledge and experience to help patients translate data into care plans. Dr. Silwitz’s post captures the history of teaching in medicine, and suggests a vision for where medicine could be headed.

    Project Millenial: “Helping Your Doctor Help You”
    Here, Dr. Peter Ubel discusses how patients can become active participants in the doctor-patient conversation. A salient theme here is the question of balance: how can patients become informed without the physician feeling threatened? In a digital age, physicians will have to navigate a doctor-patient relationship that functions on a more even playing field. On a related note, Dr. Ubel is a physician with extensive experience in psychology, behavioral economics, and business, and his book Critical Decisions offers some fantastic insight into health decision-making and the doctor-patient relationship.

    TED: “Sometimes It’s Good to Give Up the Driver’s Seat”
    Often, advocates of digital medicine and the creative destruction of medicine hold patient engagement as prima facie good. It seems that the general expectation is that patients want to be empowered, and that patients who don’t want to be empowered are explained to be that way because of the impression that the current physician-centered model of care has left on them. This TED talk is insightful because it suggests that, at the end of the day, perhaps some patients don’t want empowerment. The future physician’s role will be to balance her expertise of medicine with the patient’s expertise of his own illness narrative, and negotiate a shared agreement on a plan of care.

    NYTimes: “How Creative Is Your Doctor?”
    In many ways, standardization is a defining theme of medicine today. The evidence-based medicine ethos advocates data-driven care along research-derived ‘best-practices’ guidelines. This mentality has led some doctors to point out that patients very rarely fit to standard rubrics or checklists. Here, Dr. Danielle Ofri writes that creativity is one of the neglected virtues in medicine. Where creativity fits into the future of medicine is a tricky question; on one hand, health innovation and creative destruction demands it, but does the “protocolization” of medicine leave room for it?

    With these resources as conversation fodder, I’m interested to hear what you think. How will the social forces of patient empowerment, networked intelligence, and digital health reshape the physician’s role? Will physicians ever become truly redundant or replaceable? What are some of the important characteristics for a ‘physician of the future’ to adopt?

  10. Does Medicine Need Creativity?

    Dr. Danielle Ofri has an excellent piece this week on creativity in medicine. Dr. Ofri writes that, as medicine moves to a more standardized, evidence-based model of care, physicians should take care to preserve their versatility and creativity. After all, algorithmic thinking will never be a catch-all for all cases, and accordingly, physicians should build a sense of creativity to operate in environments of dynamism, uncertainty, and variability.

    As an aspiring health outcomes researcher, I’m inclined to think the “every patient is unique” argument for creativity in medicine is somewhat overstated. To a large degree, I believe that highly variable, loosely applicable care protocols are often areas that simply need more outcomes research to be effective. If a given clinical care pathway is effective for some patients, but not for others, it could very well signal a need for more specific research rather than ‘creative medicine’.

    One example of this is my research in psychiatric genetics. Traditionally, treatments for drug addiction have had mixed success. Some medications are remarkably successful in certain people for cessation of drug use, but completely ineffective in others. In some ways, this might signal a failure of algorithmic thinking. However, emerging molecular biology research now suggests that patient genotype can be highly predictive of treatment success.

    In other words, there seems to be a lot of variability in a protocol’s success when we examine a population aggregate. However, if we break down the population, then find the metrics that set apart respondents from nonrespondents or successes from failures, we can standardize care in a way that still reflects the inherent uniqueness and individuality of each patient. With this rationale, the gap between ‘standardized medicine’ and ‘creative, individualized medicine’ is not as large as people believe it to be. With the right outcomes research, medicine can reduce inconsistencies and variabilities to craft standard algorithms that are form-fitted to each patient.

    I still believe creativity is important. Adaptability is an important trait for physicians to have when adverse events occur, or when a patient presents with a case that doesn’t neatly conform to existing ‘evidence-based’ standards. Exposing our medical students to the medical humanities and the creative arts very likely lends them invaluable insight on the human condition and the illness experience that makes them more effective clinicians.

    But while I value creativity, I’d like to note that there’s a fine line between “creativity” and the kind of systemic variability that produces 44,000-98,000 preventable deaths and $17-29 billion in unnecessary costs per year. In an age where radical innovation and the “creative destruction of medicine” are raising a backlash to the standardization of medicine that has been underway for the last half-century, that’s an important distinction to bear in mind, and that’s why I believe we should strive for more refined standardization rather than creative medicine.