The Creative Destruction of Medicine
A Book Review
Dr. Eric Topol, one of the leading cardiologists in the nation, wrote down his predictions for the medical field in his 2012 book The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health Care. Topol’s basic premise in the book is that the massive changes that we have witnessed in technology will shake up the health care field, bringing immense benefit and a few challenges to patients. Technology is shifting medicine from a population focus to the “science of individuality.” Currently success is measured by doing some good for a certain percentage of a large population with minimal adverse effects. New developments are making it possible for us to understand each distinct individual so precisely that doctors can treat them with specially tailored medicine. Five years later, we are seeing the wisdom of Topol’s visions, especially in genetics. Recent breakthroughs are expanding our knowledge of DNA and moving us closer to editing and manipulating it to prevent serious diseases.
To be clear, when Topol talks about health care he does not mean the insurance market that many would immediately imagine. He focuses instead on the supply side of health care, how medical services are administered, and how innovation can improve the supply.
Rise of the Empowered Patient
Topol points out that medicine as a field tends to be ossified and resistant to disruptive innovation. Part of the problem is that new developments in medical technology are not making their way into the curriculum of medical schools. Molly Cooke and her coauthors in their 2010 study Educating Physicians, note the tension between the traditional approach to medical education developed over the past century and the “rapid changes in the practice of medicine” due to new technologies and drugs. Cooke states, “The future demands new approaches to shaping the minds, hands, and hearts of physicians.” Yet, the study found that “medical training is inflexible, excessively long, and not learner centered.” These conditions are producing under-trained health professionals who are inadequately equipped for a medical environment increasingly integrated with technology.
In light of this ossification, consumers will drive the coming “creative destruction” of medicine. Topol spends a large section of his book documenting how technology is empowering consumers. He explores the topics of wireless sensors, genetics, imaging and printing organs, and health IT. In each area, technology is “democratizing” medicine. The traditional asymmetry of information between the doctor and the patient is disappearing. Patients are entering the consultation room armed with a stack of data, giving them more leverage to question and provide accountability to physicians.
The Carlson Curve
Topol’s discussion of genetics in chapter five is particularly interesting, since it is a field showing great promise recently. Almost two decades ago, when the Human Genome project was completed, sequencing a whole genome was exorbitantly expensive in both dollar and time terms. The first genome sequenced took thirteen years and $2.7 billion. The price and time costs immediately began to fall. Today it generally costs less than $1,500 and takes about an hour. These changes follow the biotechnological equivalent of Moore’s Law: the Carlson curve, named after biotech author Robert Carlson.
In addition to whole-genome sequencing, several companies offer genetic tests that look for specific genes and markers related to certain diseases and conditions. These tests are even more affordable. 23andMe’s version only costs $199 and can have results back to users in a couple weeks. These changes represent astronomical gains in genomic sequencing, allowing access to a broad base of consumers. While orders for whole-genome sequencing currently must come from the patient’s doctor, an increasing number of direct-to-consumer tests could force change. At a recent Scripps conference, 23andMe CEO Anne Wojcicki admitted, “If we’re going to have this genomics revolution, it’s going to be driven by the consumer.” As prices continue to fall and science continues to discover new cures based on genetics, patients will indeed demand change.
As genetic tests and sequencing become cheaper and more available, more lives will be saved since many diseases, especially rare and serious ones, are fundamentally genetic problems. Topol documents several examples where genomic sequencing allowed doctors to properly treat and ultimately save patients. Nicholas Volker, a five-year-old boy from Wisconsin, suffered from a mysterious condition that left him frequently hospitalized and close to death. His pediatrician finally ordered his genome to be sequenced in an attempt to figure out what was wrong. The test revealed that Volker possessed a mutation in a gene pivotal to immune function. Knowing the problem led to the proper treatment: an umbilical cord blood transplant to replace stem cells responsible for producing white blood cells. Volker immediately went from near death to a happy, properly functioning five-year-old. Allowing and encouraging growth in the field of genetics will unlock the cures to more diseases and save more patients like Nicholas Volker.
Tests like the one offered by 23andMe that check for specific genetic predispositions to a variety of conditions and diseases can be especially useful for lifestyle or medical decisions. Topol tells the story of Jeff Gulcher, the chief scientific officer of a genetics company. Gulcher participated in a genome-wide scan and found that his results indicated a doubled risk of prostate cancer. Even though he was younger than fifty, he opted to have a prostate exam. The exam confirmed there were reasons to be concerned, leading the doctor to recommend a prostate biopsy. The procedure showed cancer and Gulcher underwent surgery, which he believed saved his life.
All this is not to say that there are no risks. As with a great many new technologies, there are concerns that need to be carefully considered and worked out. For Topol, “the issue of privacy is a central concern.” Information about one’s genetic information is personal information of the highest degree and contains clues as to future health and potential medical costs. This is information that employers and insurers could misuse and discriminate against individuals who have predispositions to serious conditions. This fear was a motivating factor behind the 2008 Genetics Information Nondiscrimination Act (GINA), which seeks to bar hiring and firing decisions motivated by genetic test results. (As an aside, there is a bill in Congress right now that several commentators have said undermines GINA protections.)
Other privacy concerns arise when one considers what the companies offering the tests will do with the information they have collected. Whatever the solution to these concerns, the goal ought to be to make these tests widely available. Industry driven solutions like best practice norms and voluntary certification regimes, along with the guide of the tort system, are generally the best solutions. Government regulation tends to stall innovation and, often times, leads to misaligned incentive structures.
Improving Drug Development & Approval
After exploring how technology is revolutionizing medicine in each of the four topic areas (wireless sensors, genetics, imaging and printing organs, and health IT), Topol discusses the impacts of change in Part Three of his book. One of the most consequential shake-ups that he foresees is the reorganization of the pharmaceutical industry due in large part to genetics. He envisions a new method for drug development in the age of personalized medicine that he calls the “guaranteed-to-succeed model.” Instead of enrolling thousands of patients in a clinical trial to demonstrate a small benefit, medicine can be tailored to a small number of patients that will experience exponential benefits based on their genes.
Promising results of this method are already occurring in certain oncology cases. The plausibility of this method is growing in large part because genetic medicine can precisely understand and define why and how a disease is affecting a patient on a fundamental level. If a physician can understand why exactly a patient is suffering from Type 2 diabetes, be it problems with secreting insulin or problems with insulin resistance, then the doctor can prescribe the drug that corrects precisely that problem.
This kind of genetic medicine would reduce or eliminate the need for massive randomized trials. Topol says the right kind of patient, based on genetics, could be defined from the beginning, and only a few hundred of that specific type of patient would be needed for a trial. If the drug showed promise in these patients, it would be ready for conditional approval from the FDA and made available to a wider population. After a sufficient amount of time without widespread adverse effects, the drug could be fully approved. The precision targeting of this kind of process would greatly reduce the time and cost of producing new drugs, while at the same time increasing their effectiveness.
Toward a Better Future
In the final section of the book, Topol explains several specific “deliverables” that he foresees as a result of the changes that he described.
First, medicine will shift from being reactive to making true prevention of disease possible. For the most part, people wait until they experience symptoms of a disease to seek treatment. At that point though, there may already be serious damage to the body. Through genetic testing and whole genome sequencing, patients can see into their likely futures and take steps to mitigate diseases like cardiovascular ailments and dementia. Since most of these types of problems are late-onset, individuals could have a fifty-year head start on dealing with these problems. Recent breakthroughs in genome editing technology known as CRISPR-Cas9 may even make it possible to edit out these diseases in the future.
Second, Topol foresees a “steady demise of hospitals and clinics.” Telemedicine is set to eliminate 50–70% of doctor visits. Hospitals will be reserved for serious, life-threatening illnesses rather than for long-term monitoring of such conditions as congestive heart failure and chronic obstructive lung disease. These changes will help to more efficiently allocate doctor’s time to critical, high-risk procedures by keeping low-risks patients out of the office and online.
Third, Topol imagines a world in which neuroscience allows chips to be implanted in the brain to stimulate specific emotions or even edit memories. While at the time this book was published Topol called the idea “a bit way out,” five years later the idea does not seem so crazy. Elon Musk recently began a new startup that intends to develop the technology for these functions and several more.
Finally, medicine will be able to crowd source like never before. This means that people will be able to share their medical data with their peer networks to affect better health outcomes. Online communities will develop around specific conditions, dispersing knowledge and data and spurring research into these diseases. The other aspect of medical crowd sourcing is demanding “revolutions” in medicine. Topol cites the 2011 upheavals in the Middle East that were spurred on by social media as analogies to what could happen in medicine.
Despite displaying a great deal of hope and excitement about the future of medicine, Topol acknowledges the potential downsides to these developments in the last pages of the book. To begin with, there is concern that digitizing the human being will also dehumanize the practice of medicine. It is possible that doctors could begin to treat the data rather than the individual. As artificial intelligence comes alongside doctors and telemedicine grows, the human-touch element of medicine could be lost.
Topol admits that this fear cannot be fully assuaged, but he does emphasize that the distinction between data and the real human being must be maintained. As noted, the most apparent fears related to the revolution of medicine are privacy- and security-related. Cybersecurity research becomes much more important in the context of health data. Finally, there is a concern that having access to our health data, especially our genetic predispositions, will turn us into paranoid hypochondriacs. But Topol reminds the reader never to underestimate a person’s ability to deal with and utilize the truth.
Throughout the book, Topol offers his readers a physician’s perspective on the changes he sees coming to revolutionize the medical field. Through example after example, he shows the incredible benefits that this “creative destruction” can bring. Hyperpersonalization will allow deep understanding of each individual and true prevention of debilitating diseases. No area of medicine will be spared these technological swells. But individual participation is crucial for encouraging these changes to take root. Five years later, we are witnessing developments in the fields of genetics, neuroscience, and artificial intelligence that vindicate Topol’s predictions. Though the transition has not been fully completed, science and technology are increasingly bringing that future closer. As individuals continue to demand changes to an outdated medical system, the “titanic changes” that Topol predicts will be fulfilled, to the benefit of a vast number of patients.
When the Creative Destruction of Medicine was first published, Topol showed that he was a visionary, ahead of his time. However, medical technology has developed so much in the last five years that some of the topics covered in the book seem like old news, while new fields like artificial intelligence (which I have written about here and here) are showing immense promise.
The body of literature on medical technology has also grown since 2012. Topol himself wrote a follow up book in 2015 continuing many of the same themes called The Patient Will See You Now. My Mercatus colleague Dr. Robert Graboyes wrote an excellent paper called Fortress and Frontier in American Health Care that similarly points out how technology is poised to disrupt the traditional medical framework. Graboyes and Topol will soon release a monograph (Anatomy and Atrophy of Medical Paternalism) that, among other things, discusses the motives behind resistance to technological change in health care. Numerous other authors highlight the changes that are occurring, variously praising or doom saying these changes.
The past five years have reinforced Topol’s perception that change is happening quickly and will continue despite the commentary or the actions of Washingtonian bureaucrats. These will only have the action of slowing down or speeding up the realization of these incredible developments. Topol reminds the reader that the cost of these delays is great: human life itself. Embracing and harnessing the saving potential of technology will improve society and save suffering patients.