The Future of Medicine: Megatrends in Health Care That Will Improve Your Quality of Life

Preface

This book had it origins in two parts. First, it began in my role at the University of Maryland Medical System where for eighteen years I was, successively, Executive Vice President and Chief Operating Officer, and then Chief Executive Officer of the Medical System’s flagship institution, the University of Maryland Medical Center. I believed that the key to competitiveness was to recruit physician scientists who were at the cutting edge of new advances in medicine and to secure the most appropriate new technologies that would benefit our patients in their care. This meant being up-to-date on the advances in medicine and science so that the most appropriate decisions could be made about directions and technologies.

I was constantly talking to experts far and wide, attending meetings and symposia, and reading articles to stay up-to-date. Then came a request for me to give a talk on the Future of Medicine to a chamber of commerce group. They left the contents up to me. After some thought, I decided I did not want to focus on the many problems besetting medicine today, such as the appalling lack of insurance by more than 40 million Americans; the disparities of care among the rich and poor and among minorities; the excessive governmental regulations that sap all too much time from doctors, nurses, and pharmacists; the problems of individuals using the local emergency room as their primary care clinic; and the excessive rise in health care costs without concurrent improvements in basic health measures among the population.

All very important for sure, but I decided to focus on the tremendous and exciting advances that were being made—and rapidly—in the practice of medicine. In effect, this talk gave me the opportunity to synthesize my thinking about the directions our medical center needed to be taking.

To get better prepared, I interviewed many colleagues both at the University of Maryland Medical Center and at the National Institutes of Health where I was then a member of the Clinical Center Board of Governors. Very quickly, a set of revolutions in research and development emerged, such as genomics, stem cells, and technology advances that were having a decided impact on medical care or would continue to be in the not-too-distant future. These then became the basis for my presentation.

It was new for me to talk to lay groups, but it went well, and I was asked to come back with an update the following year. Others began asking me to give the same talk—Johns Hopkins classes in management, the University of Baltimore management classes, a national law firm, even an art group. I also used it frequently when meeting with groups of potential donors to the hospital. Each time, the talk was met with great interest and the Q&A period went well over the allotted time. Eventually, I began to think this material would be a useful book for lay persons interested in their own and their families’ health. So after I retired, I decided to put these thoughts to paper. But medicine is moving fast, and I needed to update my materials and my thinking.

My process in researching this book has been to interview more than one hundred leaders in their fields. Some have been deans of medical schools or CEOs of academic hospitals, but most have been the physicians, scientists, engineers, and computer scientists who are at the forefront of medical advances. Although I had a written list of sequential questions to ask, in most cases, I began our interview with a very broad, open-ended question such as, Tell me what you think will be the major advances in medical care over the next five to fifteen years.

This was usually enough to get each person going. Then I would listen and, based on what I heard, try to keep the person on track, or I would bring them back to address an issue mentioned but not yet clarified. In some interviews when I was seeking added information about a specific topic, I was more directive and narrow, such as asking, Tell me what you think will be the major advances in stroke management and prevention in the years to come.

The material on patient safety was developed in a similar process and was also based on many interviews, this time with physicians, nurses, pharmacists, and hospital executives, along with leaders at major key organizations, such as the Joint Commission of Accreditation of Healthcare Organizations.

Everyone was very helpful and forthcoming. My next task was to find the threads of ideas that pulled all of these comments together. Being a lumper rather than a splitter, I soon had culled the information down into a group of megatrends, and it is these megatrends that are the essence of this book. Have I missed some megatrends? For sure. And will some argue that I could have lumped things differently? Certainly. But these seemed to be the biggest trends, and they were magnified time and time again by so many of the people that I talked to. I hope you find them useful.

Introduction

When I was a child my mother told me about my grandfather and his medical practice. He grew up in mid–New York State on a farm. He and his father arose by 4:00 a.m., ate some bread and drank warm milk that had been left on the kitchen table the night before, and then headed for the barn to milk the cows, fork the hay, collect the eggs, and let the animals out to pasture before returning to the kitchen for breakfast. Then my grandfather was off to school. He graduated with the first class in the first high school in the area and went to Union College in Albany.

At some point, his mother became seriously ill, and he decided to become a physician, enrolling after graduation in Albany Medical College, a medical school that required a bachelor’s degree before entry, which was still a rarity in those days in the 1890s. His mother died during his medical school years, but his father withheld the news for a while until exams were over; he didn’t want his son to be distracted.

After medical school, my grandfather did an internship and then returned home to join another physician’s practice in the adjoining town. Soon he married and he and my grandmother set out for Fishkill Landing, later to become Beacon, a small town on the Hudson River, about one hundred miles north of New York City. His office was in a room at the side of the house with a separate entrance off the large, wraparound porch that served as the waiting room. Basically, it was first come, first served until everyone had been seen. My grandmother served as receptionist, but her major role was to care for the family since her husband was so often called out. They had a phone, and it was constantly ringing with a request to see a sick family member.

Four children arrived during the course of seven years, my mother being the youngest. She often went with her father on house calls, first in a horse and buggy and later in a Model T Ford. She remembered his black bag, which carried all of his instruments plus many vials of medications. Families paid in cash—often literally pulled out from under the mattress—after he performed a delivery. Often the family or patient could not pay, at least not right away. But then in the fall, as the harvests came in, the local farmers would drop by with a bushel of apples or potatoes that would be left on the kitchen stoop.

The family lived comfortably in a modest home in a modest neighborhood and had enough that my mother was sent to a private girls’ school and then to college. But certainly they were not rich nor were most physicians of that time. It was a noble profession with lots of personal kudos and a sense of satisfaction, but also with many late nights watching over a sick child or delivering a baby on the patient’s kitchen table. Truth was, a doctor in those times could do very little to treat or cure anyone.

Medical school was mostly about becoming an expert diagnostician, one who could determine what was wrong and tell the patient and the family what the likely course of the disease would be. Diseases inevitably progressed because actual treatments were few and far between. The black bag contained mostly herbal extracts that did little, as well as morphine for pain and digitalis for heart ailments. Prescriptions were all essentially the same. Pharmacists compounded the prescriptions written in Latin, and placed them in bottles with a label that told how much to take but not what the medication actually contained, nor what it was supposed to do. It was a mystery—magic even—that was between the patient, the doctor, and the pharmacist. Sometimes it worked, mostly it didn’t. Diseases simply had to run their course, as predicted by the physician.

Caring for and attending to the patient, recommended by the doctor but provided by family members, often made the most difference. Hospitals were uncommon and were mostly meant for the dying. But hospitals did have nurses who could give what was called supportive care—food, drink, cold baths to bring down a fever, and clean bedclothes after a high fever. A good nurse could help a person back to health. So my grandfather was anxious to see a hospital built in his town, and eventually one was, just across the street from his home. But mostly his skill and his value lay in his ability to interact with individuals, tell them what was wrong, and give them hope that they would be better over a course of time—or to help them and their family deal with the fatality that was bound to be.

He died in his mid-sixties in 1936 of a heart attack. He had lived just long enough to see a remarkable change begin in medicine—based on developing science. X-rays, which had been around since the early twentieth century, allowed a doctor to check for broken bones before setting and applying a cast. Chest X-rays revealed pneumonia, and barium for enemas let physicians look at the colon or even, if swallowed, the stomach. Insulin had been discovered in the 1920s and was just beginning to be used for a few people with diabetes.

After my grandfather’s death, the first sulfa drug would dramatically shorten the course of many infections and even cure some usually fatal infections like meningitis. Penicillin was on its way. Laboratory medicine—with techniques to measure various substances in the blood, such as sugar levels or blood counts—made inroads in medical practice. And the major infections of his early practice years, typhoid and tuberculosis, for example, diminished as a result of good sanitation with water and sewers and pasteurization of milk. Some vaccines had made a big dent in diseases as well, such as those for smallpox and tetanus.¹

So the paradigm of medicine was changing from one of diagnose and predict outcome to one of diagnose and treat, a momentous change. This is the medicine that I grew up with during my years of practice, teaching, and research—one where science has been constantly uncovering new information and from it new approaches to treatment and cure. But the advances in treatment came with a cost to the patient in attention and care. Indeed, many say that medicine and physicians in particular have become cold, that the caring of the past has been lost. To some degree that is true and it is a loss of great import and of great proportion.

Without excusing my colleagues who are in too much of a hurry to see the next patient, who do not have that old-fashioned rapport with their patients, who do not spend enough time to listen and to comfort, I would add that today’s doctors can make almost everyone better to some degree and cure many. Hospitals are no longer for dying, but for complex, major operations such as heart bypass or valve replacement or kidney transplants; for treatment of cancer that would have killed earlier patients; for infusion of clot busting drugs to reverse the paralysis of a stroke; or for the repair of major trauma that in the past would have killed or maimed a patient for life.

Still, I hope that my grandfather’s compassion and commitment to his patients was passed down to me via my mother and that my patients felt that I used those skills for their benefit during the years. I think that the loss of many of the skills of my grandfather’s generation is sad, but I can also appreciate the benefits that medicine can give today.

The paradigm is changing once again. I believe it will soon change from diagnose and treat to predict and prevent. The possibility exists to know what a person is predisposed to develop with time—heart disease, cancer, diabetes, and so on. With this knowledge, the physician of the not-too-distant future will be able to prescribe a defined approach to lifestyle changes, medications, or special devices that can alter the long-term course of diseases and even prevent their appearance. Prevention will also have a dramatic effect in reducing the costs of health care, now rapidly rising.

Predicting and preventing is a major theme of this book. But other themes are presented as well, such as engaging engineering and computer science to create imaging equipment that can peer into the body in noninvasive manners, yet create exquisite and detailed anatomic and metabolic images. Or to build devices that can measure the level of sugar in the patient’s blood and then automatically administer the exact amount of insulin needed to a diabetic whose pancreas can no longer respond. Or to use the data from the imaging studies to set up a simulation of the needed operation that the surgeon will practice in advance, and then use that simulated, practiced product to program robots to assist the surgeon with the actual operation the next day—all to improve the outcome of the surgery and make it so much safer.

Information technology will be used to create an electronic medical record, one that can travel with you all the time and be available at a moment’s notice no matter where you or your physician might be. This book is about the new drugs that are being developed, often with the aid of genomic information that gives the new drug a specific target to attack, resulting in more effective medications and much safer ones as well. It is about the resurgence of ancient methods of care such as acupuncture, which are having a rebirth of respectability in medical practice, along with proof of their efficacy for specific problems, such as the pain of osteoarthritis. Finally, it is about how each of us is still responsible for our own health and what we must do to preserve it.

One more element to these advances, I hope, is about how new technologies can actually bring the health care provider and the patient back together. We can use our advancing technology to rehumanize medicine—not the other way around. Technical advances need not mean dehumanizing medicine. We can do more today; we can cure more today and this will only advance further in the coming years. We don’t want to go back to the past when there was little that could be specifically done.

We would certainly like to have magnetic resonance imaging (MRI) performed on our brain rather than undergo a lumbar puncture to extract some fluid for analysis. We would certainly prefer to have our gallbladder removed through the tiny incision of the laparoscope rather than a big incision. We would not want to go back to the days when ulcers were often treated with surgery rather than antibiotics to kill the causative germ. We are also learning that what we call diabetes in one person is not the same diabetes in another person. Each has his or her own disease and each needs care designed for him or her—personalized medicine.

So times are better, yet we—providers and patients alike—believe that the golden age of Marcus Welby is past. Providers feel overwhelmed with regulatory requirements that sap time away from patient contact; overwhelmed by the need to get permission from insurers who make their call centers slow to respond; burdened by the costs to engage clerks and billing agents rather than nurses to add value to the patient’s experience; annoyed that our health care system does not pay for preventive care, many aspects of rehabilitation care, or even for time to just sit and talk about the totality of a person’s life and how it affects his or her health and disease.

Yet we can hope that new technologies will make care more affordable, more accessible, and more personalized. We need to look at each new technology and determine if it can bring the provider back to a humane encounter with the patient. Technologies can radically alter the experience of medicine and hence the relationship between the patient and the provider—be that the doctor, nurse, pharmacist, or physical therapist. Health care providers went into medicine because in their hearts they want to be healers. The pendulum will swing away from regulations and the time-wasters so commonplace today, and the new technologies will help providers get back to being healers once again. As we develop more and more personalized medicine, I believe we will once again come back to how medicine was practiced in the past.

But now, let us look at the future and examine some of the trends—I call them megatrends—that will change medical practice and hence your care dramatically over the next five to fifteen years. Some megatrends are the result of steady advances in biomedical and bioengineering science but many are truly transformational or disruptive—megatrends that will fundamentally alter the way medicine is practiced. I have divided them into sections. The first section chronicles the discoveries in the basic science laboratories that are bringing forth the advances of genomics, stem cells, and vaccines. The second is from the engineering and computer scientists who create tiny, powerful medical devices, incredible imaging equipment, new tools for the operating room, and the ability to digitize your medical record. These advances prompt a brief discussion of rising health care costs.

The third section is back to the future, as ancient healing practices are once again becoming not only popular but also being understood scientifically. And slowly but surely we in medicine are learning basic industry approaches to improving safety for all patients. Finally, I wrap up our discussion with what each of us needs to do to maintain this incredible body and mind we were given at birth. It is our responsibility, and if we treat them well, then the megatrends in medicine will be there to help when something does go wrong.

PART I

From the Biomedical Research Laboratories

Part I looks at the dramatic advances occurring as a result of basic scientific discoveries made in the biomedical research laboratories of the academic medical centers, the National Institutes of Health, and the pharmaceutical/biotechnology industry. These discoveries are the driving forces of genomics, stem cells, and vaccine developments that will be described and how they will create megatrends in the fundamental nature of how patients are cared for by their health care providers. We will see how the concept of personalized medicine can become a reality and how some of the basic paradigms of medical care will change, such as a change from today’s diagnose and treat to tomorrow’s predict and prevent.

CHAPTER 1

Genomics—A New Era for Medicine

We have entered into a new era in medical care, the era of genomic medicine. In coming years, we will see an improved ability to diagnose a disease and even to predict diseases to come later in life. A much more accurate prognostication of what will happen as the disease progresses and how it responds to medications will be offered, and treatment will improve. Drug therapy will change so that new drugs will be more effective and much safer. Physicians will be able to select a drug based upon an individual patient’s personal way of responding to that drug, both in terms of greater effectiveness and in terms of reduced side effects.

Even the foods we eat will be understood in terms of how they affect a specific individual. Vaccines will be designed for an individual patient who has, for example, a particular type of cancer that has been reduced but not totally eliminated. Finally, actual gene therapy—the introduction of a new gene to correct one that is diseased or will cause disease—will become commonplace, such as a true cure for sickle cell anemia or perhaps cystic fibrosis. Genomics will permeate all branches of medicine.

Medical practice changed dramatically in the middle of the last century. Earlier, a physician attempted to understand what disease was present so that he could tell the patient and family its likely outcome. Specific therapies were few and far between. Then medicine became a true science with an increasing understanding of the cellular and molecular mechanisms that underlie each illness. With that developing knowledge, doctors could begin to treat disease with greatly improved medicines, such as penicillin for infections, tPA for breaking up blood clots in a stroke or heart attack, and drugs like phenothiazides for serious mental illnesses like schizophrenia.

Doctors and patients both saw penicillin as a miracle drug when it first was used to treat serious pneumonias. I am still in wondrous amazement when I see a person with a stroke come to the emergency room unable to move his left side, only to watch him stand up and walk an hour later after receiving tPA. And the state mental hospitals—long used to warehouse individuals with chronic mental illnesses—have been eclipsed by the use of potent drug therapies that get people back home and enjoying life again.

But now we are entering a whole new era. The genomic era will allow for a change in your physician’s basic approach, from one focused on detecting a disease and treating it, to one where she is focused on predicting a disease later in life and prescribing a preventive approach. (I use the pronoun she here to emphasize another major trend in medicine—today over 50 percent of medical school students are women.)

Consider Anna Blumenthal, a thirty-four-year-old single woman employed as a financial consultant with a major accounting firm in the mid-Atlantic area.¹She began to have intermittent episodes of breathing difficulty and her doctor diagnosed asthma, a condition in which the smooth muscles around the airways deep inside the lungs begin to constrict, making it difficult to move air in and out and creating the characteristic wheeze during exhalation. Her doctor reviewed a variety of things she could do at home to reduce her chance of developing asthma attacks and gave her some preventive medications as well. He also gave her a prescription for an albuterol inhaler and told her to keep it handy for use in case of an asthma attack.

She followed her doctor’s instructions, making some changes in her environment and taking the preventive medications regularly. However, at about two o’clock one morning, she woke up, struggling to breathe. Alone at night, it was scary. But she remembered the albuterol that was in her medicine closet. She had read the instructions before but now read them again.

Albuterol comes in a spray canister; you put your lips around a mouthpiece, press down on the canister, and out comes a measured amount of very fine spray. The idea is to press the canister while taking a deep breath in, so that the medicine will get deep into the lungs. Albuterol works because it interacts with a receptor on the lining of the airways of the lung, a receptor that can relax the smooth muscles that are causing the constriction. When albuterol finds that receptor, it breaks the action of the smooth muscle constriction. It doesn’t cure the underlying cause that created the constriction in the first place, but it can turn the attack around in the short term. This receptor is the product of a specific gene that is part of our DNA. So we can say that our DNA directs the production of this receptor along our airways that will respond to albuterol.

Anna knew that after breathing in the albuterol she should begin to feel relief within a few minutes. She put the mouthpiece in, depressed the canister, breathed in the spray, and repeated it about a minute later, as directed. Then she waited, but nothing happened. Indeed, it was getting more difficult to breathe not less difficult. Now she really was scared because the promised relief had not arrived. Why? Because Anna is one of those rare people who are born with a gene that directs the production of a slightly different receptor on the lining of her airways, and this slightly different receptor does not respond to albuterol.

The middle of the night during an acute asthma attack is hardly the time to discover that you are among the unfortunate few. But for years physicians have been unable to predict which patients would not respond to albuterol. As a result of genomics, soon it will be possible to know who will not respond, so that an alternative medication can be prescribed and a long night of dis-tress—and fright—can be avoided.

DNA and the Creation of Proteins

The genomics era began at the start of this century with the preliminary sequencing of the entire human genome, a task that was completed in 2003. What does this mean? How does it affect your medical care? A brief review of the structure and activity of DNA will be helpful before I attempt to answer these questions.

Left—DNA double helix; Right—Demonstrating the linkage of A to T and C to G Courtesy Thomas Jemski, University of Maryland School of Medicine.

Deoxyribonucleic acid (DNA) is made up of molecules of four substances (nucleotides) that are named adenine (A), thymine (T), cytosine (C), and guanine (G). For our purposes let’s just use the letters A, T, C, and G. They are attached to a backbone of sugars and phosphate. DNA has two main jobs. One is to replicate itself and the other is to direct the production of proteins.

Replicating itself allows a copy of DNA to be created whenever a new cell is created. Proteins are critical cellular compounds that control a cell’s basic functions and structure. DNA ultimately establishes what a cell is and what it does. Proteins, in turn, are made up of molecules called amino acids of which there are twenty types, all arranged in a specific sequence that is different for each protein. DNA directs the sequential arrangement of amino acids, a task accomplished by the arrangement of the A, T, C, and Gs of DNA.

Each and every cell has our entire DNA. Half of it comes from Mom and half comes from Dad. It’s arranged in units (chromosomes), twenty-three from each side of our family for a total of forty-six. DNA is basically a long chain of those four letters A, T, C, and G. These four letters make up the genomic alphabet. They can be put together in groups of three that code for a specific amino acid.

For example, ACA is the code for the amino acid histidine, which is one of the twenty that make up proteins in the body. CAC is the code for threonine, another amino acid that makes up protein. These three-letter codes are called codons, and we can think of each of them as a word in our genetic dictionary. Consider a long chain of ACACACACACACAC, and so forth. This would be a code for alternating the amino acids histidine and threonine.

Dictionary of Genomics

A set of codons, which we can call the gene, is the blueprint for the structure of a protein. In my example of ACACACACAC, we are not making a true protein but an alternating chain of these two amino acids. The process goes like this: Our gene, which would be part of the entire strand of DNA, directs the creation of a related compound called mRNA (messenger RNA). The mRNA, which holds the same code,² travels to a part of the cell called the ribosome; a ribosome is basically a protein manufacturing factory. The ribosome takes the mRNA and follows the code, in this case alternating ACA, CAC, ACA, etc., and puts together the alternating amino acids histidine and threonine.

A real protein, such as insulin or hemoglobin, is made up of many different amino acids and usually is many hundreds of amino acids long. After it’s manufactured by the ribosome, it folds into a complicated shape that might look like a ribbon sort of wiggled together on the floor after coming off a Christmas package. In fact, that shape is very specific and allows for the creation of an active site on the protein, which is the part of the protein that causes something to happen, such as relaxing the smooth muscles around the airways.

How much DNA do we have in each of our cells? If we were to read one letter each second it would take about one hundred years to read all the DNA in those forty-six chromosomes. We have about thirty thousand genes and more than 99 percent of these are exactly the same in each and every human being. It’s the few that are different that create the differences among us and explain why one person will respond to a drug and another will not. Or why one person will have no side effects while the same drug in another person will cause major toxicity. But more about this later. What I hope you have gathered so far is that DNA is indeed the code of life and that our new understanding of the genome will open many previously closed doors.

IMPLICATIONS OF GENOMICS ON MEDICAL CARE

Still to come is to understand the exact sequence (those coded four letters A, T, C, and G) in each of the thirty thousand genes and to determine the function of each gene.

As this is done during the coming years, it will become possible to predict who might be more susceptible to a disease, such as atherosclerosis (clogging of the heart’s blood vessels), diabetes, or perhaps colon cancer. Knowing that a person is at higher risk will allow the physician to recommend a preventive approach, such as diet and lifestyle changes, for each of these diseases—attention to cholesterol levels for the person at risk for atherosclerosis, weight control for the person predisposed to diabetes, and to an early start with screening colonoscopies for the person at risk of colon cancer. It will allow drug companies to create specific drugs to counter a disease while avoiding unwanted side effects and will allow the physician to choose the drug that will be known to work