Topol on The Creative Destruction of Medicine

In this episode of Medscape One-on-One, Dr. John Reed interviews Dr. Eric Topol, author of The Creative Destruction of Medicine, about how technology is changing medicine, making diagnosis and treatment faster, better, and more accurate. Topol says that cutting-edge medical technology, coupled with everyday devices like smartphones and tablets, is empowering physicians and patients alike.

Introduction

John C. Reed, MD, PhD: Hello, and welcome to Medscape One-on-One. I'm Dr. John Reed, Professor and Chief Executive Officer of Sanford-Burnham Research Institute. I'm joined by Dr. Eric Topol, Director of the Scripps Translational Science Institute and the cofounder and Vice Chairman of the West Wireless Health Institute. Welcome, Dr. Topol.

Eric J. Topol, MD: Good to be with you, John. [Editor's note: Dr. Topol is also Editor-in-Chief of Medscape Genomic Medicine and theheart.org.]

Biggest Shake-up in the History of Medicine

Dr. Reed: In addition to the institutes you've started, you're also a practicing cardiologist and a professor of genomics. An esteemed scientist, you recently produced a new book called The Creative Destruction of Medicine. Tell us what prompted you to write that book.

Dr. Topol: It was actually this ability to see where medicine was going with genomics and wireless sensors. For the first time ever, we're starting to be able to digitize human beings. If we can do that, we can really radically disrupt medicine. That's why the term "creative destruction," coined by the late economist and political scientist Joseph Schumpeter, came into play, because we're going to a whole different way of individualized care and prevention. It really sets up the most exciting, biggest shake-up in the history of medicine.

The Digital Revolution

Dr. Reed: The book really discusses this digital revolution and how it can change medicine for the better -- but only if we let it or if we have the will to do that. What do you mean by that?

Dr. Topol: Up until now there's been this incredible digital infrastructure which keeps ratcheting up with not just the mobile world of connectivity and broadband, but also with super computers, cloud computing, and social networks. But for all intents and purposes, that has been a separate orbit in the medical community and in our medical microcosm or cocoon, as I like to refer to it, because we haven't let that digital world come in. It's barely intersected. We've scraped the surface in electronic medical records and health information systems, but we haven't embraced technology where it counts, and we now have a fantastic opportunity.

Resistance to Change

Dr. Reed: Are you seeing reluctance on the part of the medical establishment to embrace these technologies that are available today and which could redefine how society approaches healthcare?

Dr. Topol: Yes. This is the first time I ever wrote a book for the public, for consumers, because I recognized that the medical establishment is ultra-conservative, which is why it has resisted this digital opportunity. The only way to really take it to the public and to consumers is through their smartphones: It's their DNA, it's their social networks, it's their everything. If they are educated about the opportunity here, they can help drive this. We've already learned in the past that when patients ask their doctor about a prescription drug it has a very striking effect. What will happen when they can go with their data to their doctors and say, "Help me; partner with me"? That could set off a whole different way of practicing medicine in the future.

How Technology Is Shaping Medicine

Dr. Reed: You mentioned in your book that in many ways medicine has improved because of the digital revolution. Share with us a few examples of how that technology is shaping medicine today.

Dr. Topol: It's just beginning, in some respects. You can press a button on your phone and you can get all of your blood pressures graphed, digitized, and archived in your phone and then send it to either your doctor or your Facebook friends -- whatever you want to do. We have never had that before. You can get glucose readings every 5 minutes around the clock, which allows doctors to do remote monitoring. Obviously we also have these online health communities, like PatientsLikeMe and CureTogether. The issue there is that now patients are turning to their online networks for virtual peers to get guidance about like medical conditions; many of them trust these virtual peers they've never met more than their doctors. These are things that no one would have predicted. Of course, the social network movement in itself has far exceeded anyone's wildest expectations, but it's really starting to get into the medical sphere now and it's having an impact, which was unforeseen and is still not even recognized by most physicians today.

The Good and the Bad of Technology

Dr. Reed: It's really amazing what has happened. I know you talk about the Internet being a vehicle that has allowed patients to be more informed than ever -- but also potentially more misinformed than ever. Can you talk a little bit about the good and the bad side of that?

Dr. Topol: The good side is that there is the Internet and it can disseminate information, but unfortunately we still can't control the quality, and that's been a problem from the beginning. The quality gets better over time but, for example, there was something called "the YouTube cure." It was about a video on multiple sclerosis treatment that involved putting stents in the veins in the neck, with the blood coming back from the brain. Consumers thought that you could cure multiple sclerosis doing this. But it doesn't make a lot of sense medically. The "cure" started in Italy, and because of the Internet and YouTube, it caught on like wildfire -- not just across Europe and the United States but especially in Canada. Of course, the video didn't have any positive effects, but that's the danger of the Internet. But there's a plus side that's coming now: Instead of the Internet where you'd look up information about a population of people, now you can look up your own data. You, as a patient, have a sensor. Or let's say that you're looking at your genomic data for a drug interaction with specific genotype. It's your data now. That's a whole different world. You're not looking at something for someone else; now we're talking about an extraordinary -- really a tectonic shift -- from population medicine to individual medicine. I think that is really the plus side of all of this.

Patients Will Share Their Data

Dr. Reed: You mentioned this idea that it's the patient's data. Do you think patients are going to be willing to share their data? We give a lot of attention in this country to privacy around healthcare issues, but privacy also can slow down progress in the sense of not being able to share data that we could learn from. Where do you see most patients on that issue?

Dr. Topol: It has really been surprising. I go back to the online health communities like PatientsLikeMe and CureTogether: There's absolutely no unwillingness to share everything with people that they've never met. People who belong to these online communities are putting all their data on their medications and their lab tests and their scans and whatnot out there. So when people are affected with a significant condition and are looking for better treatments and useful information, there doesn't appear to be any reluctance. The other thing is that young people have grown up as digital natives whereby they have no reluctance about sharing everything. Everything is transparent. This may be foreign to us digital immigrants, but the young folks are not as concerned about privacy of health matters compared with people of more advanced age.

A Better Way to Foster Innovation

Dr. Reed: I think we all believe that it's going to be important to get that balance right if we're going to move this personalized digital medicine forward. But let me change subjects a little bit. In your book you talk about the innovations that are possible, but you also worry that this country isn't doing enough to foster innovation. You discuss how governments have done much to further access to healthcare but have not done enough to foster achievements in healthcare that translate and improve outcomes. What do you think government should be doing to encourage more innovation in medicine today?

Dr. Topol: With respect to innovation, this is what I worry about. We are not in a conducive environment to advance innovation. For example, we have such a risk-adverse regulatory environment that, in order for a new drug to be approved, it has to be tested in so many large numbers of patients that it takes years before that drug ever sees the light of day in the real world. The problem with that is that the clinical trials are artificial; they are not representing the real world of patients. I would like to see this process unleashed. With electronic surveillance, we could get a drug out there much earlier without formally approving it. For example, if we know that a drug has efficacy, we could get it out to the patients who need it and the safety side could be monitored electronically with every single patient who gets it. That's just one example.

We also don't have the support of this hyperinnovative digital opportunity that lies before us, and if we could ratchet that up and really foster innovation, the whole digital revolution in healthcare could come about more quickly. That's why I'm appealing now to the consumers rather than the medical community, because the power of the people through social networking is profound now. Consumers can help foster and accelerate innovations.

The Role of the FDA

Dr. Reed: I'm glad you brought up the issue of regulatory policy as pertains to this new era of personalized medicine. The FDA has the chief regulatory authority and they have a tough job to do. They have to protect the public. They're trying to get that balance right between risk vs benefit, but all too often it seems that the tendency is to be more risk-adverse than many of us are, including the patients who so desperately need new therapies. What do you think the FDA is doing right, and what could it be doing better in terms of making possible this whole new era of personalized medicine?

Dr. Topol: We have seen that in recent months the FDA has actually approved more drugs than in a long time, and they're approving genomically guided drugs, particularly for cancer, and also a drug for cystic fibrosis. So this whole individualized medicine era is taking hold. I give credit to the FDA for accelerating or streamlining the process for this. The issue, though, is that we need new models. For example, instead of the sacrosanct randomized controlled trial of thousands of patients that has to extend over years, why not do small trials because we get so much more data? We can get whole genomes in addition to biosensor data. Why don't we use these rich data on each individual to do small trials to get hyperefficacy, and then get these interventions -- whether they are drug, device, or diagnostic -- out in the real world as early as possible and use the new tools of digital monitoring in this electronic world to ensure patient safety? Being stuck in this entrenched way of the randomized trials of yesteryear is holding us back. We need to adopt new models, which, to the FDA's credit, are being looked into. But they don't move quickly.

For example, we could genotype a drug like carbamazepine. In Taiwan, patients can't get carbamazepine unless they are first genotyped to see if they are at risk for Stevens-Johnson syndrome. In the US, we know this risk exists and we know the European allele that raises this risk, but we don't genotype patients who are prescribed carbamazepine. I recently asked an FDA official why this isn't a routine practice in the US, and the answer was, "We're working on it." We could work faster and that's one thing I'm trying to encourage.

Is Personalized Medicine Too Abstract?

Dr. Reed: Let's talk a little bit again about this personalized medicine idea that you write about. You think this sort of one-size-fits-all mentality in medicine will soon be replaced by highly personalized solutions enabled by the breakthroughs in genomics and by mobile devices that can remotely sense what's happening in a patient's body. You speculate that these advances will be driven less by doctors and more by consumers, patients themselves. I certainly agree with you, but there are some who would argue that highly personalized medicine is still many years away. We still have a lot to learn about genomics, and what we do know about genomics is not terribly translatable to practice today. Some even submit that this personalized medicine is too expensive and untested. How would you respond to this point of view?

Dr. Topol: We've heard all the naysaying arguments with that one. I think it's going to happen. This is inevitable. It's just a matter of when. The question is, what is the plasticity of the medical community? What is the willingness and initiative that could be taken on the physician's side, or is this going to have to all be driven from the consumer's side? It has to happen because we are in a situation that's untenable and unsustainable in healthcare today. We can move to a whole new plateau where we have so much more data on each individual that we didn't have before. Whether it's high blood pressure or trying to prevent the progression from prediabetes to diabetes, we have new tools; there should be a new day in medicine if we are willing to accept that and try to catalyze this opportunity.

I think there are always going to be naysayers, but if you start to integrate this into practice and you are seeing this kind of a striking contrast to old medicine, you will realize that this really is a new medicine. It's self-perpetuated and exhilarating, and that's how I practice cardiology. I haven't used a stethoscope in over 2 years to listen to the heart. I use a portable high-resolution ultrasound, and I'm thinking, "Why would you use a stethoscope?" But I used to teach residents and medical students the bedside exam, and the stethoscope was part of that. I wouldn't use a stethoscope again, except maybe in a rare situation in which I was puzzled by the ultrasound. But the ultrasound tells me everything in a minute or two. That's just one example and that's in our field of cardiology, but for every era there are new tools that are not being used as they could be.

Prevention Before Treatment

Dr. Reed: It seems that these new tools also would give us the opportunity to change the emphasis on healthcare from one of managing crisis to one of wellness and prevention, because these tools could give the patient, the consumer, real-time feedback about how lifestyle changes or medication changes are affecting their health, providing positive reinforcement. Could you talk a little bit about that?

Dr. Topol: I always try these things on myself first before I unleash them on the patients. For example, I tried the glucose monitor which is right on the phone as a sensor. I did that for a couple of weeks and knew it was incredible. I learned exactly which foods would bump up my glucose off the charts and I'm saying, "Oh my gosh, I never would have known that." We never had this data before, and now all of a sudden it's on your phone and all your vital signs will be on your phone. You name the metric -- anything from quantifying mood to brainwaves -- it's all going to be on your phone.

For the consumer it's a new day, and that's how I believe this new model -- going back to your question about partnership -- is going to occur, because the consumer is fascinated by data they've never had before. Of course, it has to be processed in a way so that doctors are not getting flooded with data from hundreds of patients, but if it's properly handled it provides a whole new way of partnering between the patient who has lots of information about himself or herself and the physician. This is not what we have right now. We've kept all the data away from the patients. There have been recent articles in JAMA asking whether patients should have access to their laboratory tests. How can you ask that question now? We're in 2012; asking whether patients should have their genomic data is history. They're going to have access, so now we have to deal with that and actualize it to ensure the chance for better treatment and prevention.

Educating Physicians and Consumers

Dr. Reed: Let's talk a minute about education. For consumers to be educated users of these kinds of tools, what do you think has to change? I'm often amazed at how people seem to know more about how their car works than their body; maybe that says something about the way we teach biology and health in our high schools. What do we need to be doing as a society to prepare people to be participants and partners in a new era of healthcare?

Dr. Topol: You're absolutely right about the car, with all of its sensors telling you about tire pressure and your engine and every other aspect. We don't have that for our bodies yet. What's wrong with this picture? The big gap here is education. We need to educate our physicians and healthcare professionals. We also need to educate consumers. I took on that mission of educating consumers with a book to at least try to get the conversation started and to help people realize what is out there, but I would love to see a curriculum built for the medical community to get them up to speed in genomics and wireless sensors and advanced imaging. Right now, when you talk about digitizing human beings and digital medicine, it doesn't excite a lot of doctors. They're thinking about electronic medical records. They're not thinking about the fact that we can digitize a human being to know the essence of what makes each person tick, and when you do that it's a life-changer. That's a big event, so when we start to educate our colleagues, that could be something that will be transformative. I'm eager to see that happen.

Medicine in 10 Years

Dr. Reed: Let's think ahead about 10 years from now. What's really exciting to you? What do you see coming? What are we going to be doing a decade from now in medicine that is going to be transformative and that gets you fired up?

Dr. Topol: What we're seeing right now is just the beginning. Obviously we've still got to integrate these things. You may have somebody's whole genome sequence but you won't have their biosensor data or their imaging, so you have to pull that together with all of their other information so that it can all be integrated. But the next phase goes back to the car analogy: embedded sensors. With this technology, you put a nanosensor smaller than a grain of sand in the bloodstream, whereby it's sensing whether you have that single cancer cell that shows up long before any scan could possibly diagnose it. It could also sense whether you're genomically at risk for type 1 diabetes by showing that the Islet cells are getting attacked. Then you've got 5 years to work and reverse it. You should be able to prevent diabetes or heart attack using this technology.

We're doing work at Scripps where we can identify those cells that are coming off the artery, which could undergo a plaque rupture days or weeks later, and using that information to prevent heart attacks. What's most exciting to me is the opportunity for prevention. We've talked about it, and of course everybody is supposed to be on a diet and exercising. But we've got to do much more than that because even people who have the healthiest lifestyles are vulnerable to the worst diseases, so we can be smarter by digitizing people. That might require embedded nanosensors or something else, but that's what will lead to this greatest shake-up in the history of medicine.

Dr. Reed: To use the car analogy, certainly we don't have to wait for steam to start coming out of the engine of our car because a sensor tells us that something is wrong first. Because of that, we have preventive maintenance, so that's a great analogy.

Dr. Topol: Taking a step back, everything we do today is like that, like waiting for the steam to come out of the engine. You show up with a heart attack, you show up with pneumonia, heart failure, diabetes -- the car is on fire and we've got to get out of this mode. The new tools set up an extraordinary path to prevention going forward.

What’s Next for Eric Topol?

Dr. Reed: We're excited about it. We just hope the FDA will approve them. You have had such a diverse career. You're very much involved with genomic health and you're involved in genome sequencing and connecting that information to patients. You're also a practicing cardiologist. You've got your new book out. What's next on the horizon for Eric Topol?

Dr. Topol: I'm just trying to help nurture this field. There are lots of different directions to go in. I'm hoping to get the educational part of it, particularly for physicians, into high gear. I'm hoping to contribute to the whole concept of embedded nanosensors. I've never had so much fun in my life. This is something that is more than rejuvenating and energizing. People used to ask me why I keep working in genomics and wireless -- what do they have to do with each other? They have everything to do with one another; it's the same thing. And when you start to realize that, from a medical standpoint, we are all just lots of zeroes, ones, and ACTGs, if we can get all of that critical information on patients, then we can change healthcare. That's something that has to change.