The Future of Medicine?

Leroy Hood proposes the “P4” view of medicine in an interview in MIT’s Technology Review (http://www.technologyreview.com/biomedicine/24703/page1/). The four P’s are Powerfully Predictive, Personalized, Preventative, and Participatory. These apparently will be the underlying concepts in, as the article puts it, a “revolution in medicine”. Really? I’m not so sure.

Don’t get me wrong. Leroy Hood is one of my science heroes: he was a rising star when I was a graduate student and post-doc. Subsequently, he has offered ideas and generated energy in areas of molecular biology that I really like, having helped invent automated sequencing and started an institute to promote systems thinking around cell and molecular biology. He is one of the smartest people that I know of.

However, in my mind there is a strong case that three of these “P”s, Predictive, Personalized, and Preventative are really not new. These concepts in medicine have been the subject of discussion and goal of improved medicine for many years. The impact of genomics and informatics on these three will be, in my opinion, an extension of work that predates DNA sequencing and computers. The one “P” that I think may be revolutionary is “Participation”.

Predictive describes what we all want our tests to be. If I take a glucose tolerance test, my physician is attempting to gather information on whether I have diabetes or not. With that information in hand and armed with knowledge of the natural history of people with or without the disease of diabetes, my physician can “predict” what my health state is likely to be at some point in the future (under certain assumptions). If you think about it, there is no test that can actually predict the future. They are all educated guesses with some probability of being wrong attached. The same will hold true for genomic based tests. Sorry, 23 and Me. More on this in a future post.

Personalized and preventative are likewise extensions of long-standing trends in medicine. Physicians have been working to personalize care for eons through practices such as prescribing different doses of drugs for different size people. And, as has been discussed for the last decade, there are some very powerful disincentives for personalizing therapeutic products too much: highly targeted market = small market.

Preventative even has its own cliché (I prefer to call it “distilled wisdom”): “An ounce of prevention is worth a pound of cure”. Whether the technologies mentioned in the article will have the impact on these long-standing trends in medicine that the hype has built up for them remains to be seen.

For my money, the one “P” that does have a case for being revolutionary is Participatory. For a long time patient participation in medical decision making was pretty much discouraged. Certain shifts in social structure, along with the huge increase in the availability of medical information in the last 30 years have opened the door to patient participation in health care decisions. Now, if I am a man, I have available to me more information about prostate disease than I can possibly absorb. Similarly, women can learn all that they want to know, and more, about breast cancer if they have access to a computer with an internet connection. Whereas one used to rely on one’s physician for the required information on whatever health problem, now the patient has the capability to acquire information on their condition and the available treatment options. As a result, each of us, in most of our health care situations, is empowered to participate in the required decision making. Is this where informatics will have its greatest impact on the revolution in medicine, rather than in terabytes of sequence data?

So, perhaps the real revolution in medicine is in patient education for its ability to facilitate participation in one’s own health care. As discussed in this recent article, nearly all women who received information on their breast cancer from the Oncotype Dx test from Genomic Health, Inc. were glad they took the test. However, only 2/3 to ¾ said they understood what the test was telling them, even when explained by their physician. So, to really participate in their health care decisions, these women need to understand what breast cancer is, what genomics is and what it can tell them about their disease, and how this information can support their decisions. I believe that from a collaboration of an informed, educated patient and their physician will come the best health care decisions of all.

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