Destroying Medicine to Rebuild It: Eric Topol on Patients Using Data

By David Ewing Duncan

In his new book, the cardiologist and director of the Scripps Translational Science Institute is on a tear to transform health using the latest tech.

Image: viviami/Shutterstock

The emergency announcement on the transcontinental flight was terse and urgent: "Is there a doctor on board?" A passenger in distress was feeling intense pressure in his chest.

Eric Topol strode down the aisle to examine the passenger to see if he was having a heart attack, a diagnosis that normally would be tough at 35,000 feet. But Topol was armed with a prototype device that can take a person's electrocardiogram (ECG) using a smartphone. The director of the Scripps Translational Science Institute near San Diego, he had just demonstrated how it worked during a lecture in Washington, D.C.

"It's a case that fits over your iPhone with two built-in sensors connected to an app," says Topol, showing me the device, made by Oklahoma City-based AliveCor. "You put your fingers on the sensors, or put them up to your chest, and it works like an ECG that you read in real-time on your phone."

"So I put the sensors right on the man's chest," he continues, "and I could tell he was having a heart attack. I said to the pilot: 'Get this guy off the plane, this is the real deal.' And they made an emergency landing. My understanding is he did very well."

Eric Topol has turned on his AliveCor sensor and tells me to press my fingers on the two slim metal sensors on the back of his phone. Immediately my pulse hops across the screen.

I'm now sitting with Topol in his office just above the Pacific Ocean in La Jolla, California, as the sun sets and hang gliders soar over an impossibly idyllic beach. He has turned on his AliveCor sensor and tells me to press my fingers on the two slim metal sensors on the back of his phone. Immediately my pulse hops across the screen, settling in at a normal 70 beats per minute.

"I use it when I see patients," he says. "I don't do a formal cardiogram anymore. If you had some heart arrhythmia or you were prone to dizziness, lightheadedness, or pounding -- we'd give you one of these, you'd put it on your phone." He tells me the device has yet to be approved by the Food and Drug Administration (FDA) in the United States, but it's about to be approved in Europe.

"This can't come fast enough," he says with intensity, a tall, lean man who is big like a professional basketball player is big. His face is narrow with the perpetual half-smile of a physician wanting to convey both good humor and authority. "This device is ready right now to save people in ways that has never been possible before."

Topol speaks with the same ardor and edge that led him in 2004 to publicly challenge drug giant Merck about the safety of their then-multi-billion dollar pain drug, Vioxx. Vexed by their refusal to acknowledge a potentially fatal side effect of the drug for patients with heart disease, Topol also went head-to-head with the leadership of the Cleveland Clinic, where he then served as chair of the department of cardiology. The flap led to Merck pulling Vioxx from the market, and to Topol's departure from Cleveland Clinic.

Now Eric Topol has now written a book that calls for the "creative destruction" of the current medical paradigm, which he believes has failed to keep up with the digitized world of interactivity, social media, computers, apps, and advanced engineering and electronics. In the book, written in that same half-smile style of good humor and authority, Topol blasts current-day medicine as being archaic and wasteful, making his case with a compelling blend of statistics, anecdotes, and barbs aimed at health care's Ancien Régime.

If at times he seems a whiff too optimistic about the transforming impact of new medtech in the short term, he does a good job of explaining subtleties to a lay audience -- such as why some genetic testing for predicting disease is valid and useful, and why much is not.

I came away wondering, however, if there was going to be a Creative Destruction, Part II that delves more deeply into exactly how the destruction and rebooting Topol proposes will happen. As Thomas Kuhn wrote in The Structure of Scientific Revolutions, changing paradigms is not easy. "No part of the aim of [traditional] science is to call forth new sorts of phenomena," Kuhn wrote, "indeed those that will not fit the box are often not seen at all."

As Topol rightly points out, the barriers are formidable, from an FDA struggling to keep up with an explosion of new technologies to a reimbursement system for health care that favors expensive and complicated tests and procedures that utilize hospitals and massive infrastructure. Topol believes that consumers teaming up with innovators in the med-digital world are the key to forcing change, which is certainly true. But how exactly will this work?


Below are excerpts from the rest of my conversation with Eric Topol.

In your book you write about the need to destroy the current medical system and start over. What's wrong with how we do things now?

The current system is outmoded. Most important is how the medical community is failing to take advantage of radical new technologies that allow us to treat patients as individuals. Medicine is still all about treating populations, not people -- one-size-fits all treatments and diagnoses. We now have the capacity for digitizing human beings. We've never had the ability to measure blood pressure 24 hours a day, or heart rhythms whenever you're not feeling right, or blood glucose levels every minute. But it's even deeper than that, it's using data to get to the root cause of disease in individuals so you can prevent illnesses for the first time.

Can you give me some examples?

I have this device where I can measure my glucose every minute and download it to my phone -- you attach a sensor with a little needle and you wear it on your stomach, or under your arm. Seeing your glucose every minute on your phone, it really changes your lifestyle. You ask yourself, "Do I really need that piece of cake? No, because I don't want to stress out my pancreas."

So can you really see the spike of sugar. How quickly does it happen?

Oh, immediately. It's unbelievable -- you're chewing and minutes later it's there. This device is pretty important when the world has a billion pre-diabetics and 400 million diagnosed diabetics. If we could start getting people to use these monitors linked to their smartphones -- you know there are more cell phones than toilets or toothbrushes in the world? If we could get people to use this on a smartphone, even for a week, maybe we could get a handle on the diabetes epidemic.

One sensor that's ready now is the wearable blood pressure cuff.

How are you going to take blood pressure during sleep? Or when you're in an argument, or stressed? Soon you will be able to get your blood pressure anytime and have it on your phone. Seventy million Americans have high blood pressure. Half of them have poor control and they're sitting ducks for a heart attack or stroke. This is a big time game-changer.

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But isn't there a huge problem right now with devices that can collect massive amounts of data when we don't yet know how to interpret it?

Yes, now the problem is no longer getting access to data, whether it's a genome sequence or whether it's a glucose sensor, but how do you process that data in an efficient way, getting the juice, the distillate? Once this thing goes to scale, you've got to have algorithms and auto signal processing.

Topol pulls out another device, a portable ultrasound about the size of book with a wand connected by a wire. Called the Vscan, it's manufactured by General Electric.

Have you seen the Vscan, it's a portable ultrasound. I use this instead of a stethoscope. I haven't used a stethoscope as a cardiologist in about two years now. As part of a routine physical exam, I do a full echo of a patient's heart. I see the valves, the chamber, the whole thing. Why would I listen to the heart go lub dub? This has been out since February 2010. And each echo exam is free once you buy the thing, which is about $7,000. It costs something like $800 every time you send someone to the echo lab, and they do this ritualistic 45-minute study. I do this as part of the physical exam in one to two minutes. This is the modern stethoscope, the real deal -- scope means look into -- for me.

Why isn't this being used by all cardiologists today?

Because they don't get reimbursed. The hospital loses a charge of greater than $500 and the doctor loses his fee. There are 20 million echocardiograms done a year. How many billions of dollars is that? This is two-year-old technology.

You are being very careful not to sound too negative in this book, but how do you really feel about the rather substantial hurdles to creative destruction happening as you envision it?

I believe that change is already happening, but it's not going to happen from within the medical community. It's going to come from consumers. That's why I wrote the book, to take this case to empowered consumers that can educate, activate, get their social networks going. Let's say they go to the cardiologist and say: "Doctor, why are you using a stethoscope? If you're writing me a prescription, why aren't you getting my genotyping done for that drug?"

You are talking about using genetic differences in people that cause drugs to work or not work, or to be safe or not to be safe?

You can now get genetic information on over 25 drugs before you get the prescription filled -- if you're going to respond, or you're going to have some horrendous side effect.

In my own genetic testing, I discovered that I'm hypersensitive to warfarin -- blood thinner. It's dangerous for me to take the usual dose.

Yeah, I'm also hypersensitive -- would need to take 2 mg instead of a 10 mg dose.

There is another genetic test for a side effect for statins -- myopathy, or weakening of the muscles.

That's the SLCO1B1-5 gene. We should use it today for everyone who takes statins, at the time of initial prescription. Why do we make so many people suffer? Some people get myopathy so bad they can't even get out of bed. They think they have the flu, but it's the drug.

This seems to be asking a lot of medicine, which still mostly keeps records on paper.

Yeah, you're still getting articles in top-tier journals that ask things like: "Should patients have access to their laboratory tests?" That was in JAMA [Journal of the American Medical Association]. Then The Wall Street Journal a few weeks ago talked about: "Should doctors email with their patients?" And you realize that 62 percent of doctors do not email their patients. I say to this: "Help me, it's 2012!" The ultimate one was when the American Medical Association lobbied to deny patients access to their genomic data without a doctor. But the AMA also conducted a survey of their own people -- us doctors, 10,000 of them -- and 90 percent said they have no comfort whatsoever in dealing with genomic data.

In the book you talk about the need for "super-convergence." What is this?

Right now, medicine is all about silos. We've got genomics, and sensors, and imaging devices. We need all of this data to be integrated for each individual, and for the convergence to be superimposed with the global digital infrastructure. This infrastructure has not yet intersected with the medical world. For example, let's say you sequence fetal blood from a mother in the first trimester, and it turns out the baby's got a high risk of juvenile autoimmune diabetes. It takes five years after birth for a pancreas to go bad. So now you know the risk, so you can place an embedded sensor to monitor for an active immune attack on the child's pancreas, which can be treated and the diabetes headed off.

You have criticized the medical community for claiming to be evidence-based, which you say isn't always true.

Evidence-based medicine is a fancy buzz term. You've got people who draw out guidelines from shaky data and tell the world this is the way it's got to be. A great example is statins. The medicine community promotes them like crazy. But for people without previous heart disease only one in a 100 people will benefit in terms of preventing heart disease. And then you have the FDA issuing a warning that taking statins can increase the risk of diabetes, which is at least 1 in 200 for the more potent statins. For people who have heart disease, statins are great. But if all you've had is high cholesterol, what you're doing is taking this 1/100 chance of getting a benefit and offsetting it with 1/200 chance of getting diabetes. What kind of trade off is that? We've got to get more intelligent about the individual's true benefit to risk story.

Recently, Topol wrote an op-ed in The New York Times entitled "The Diabetes Dilemma for Statin Users" that expands on the link between statins and diabetes.

So how do you overcome this?

Well, I would throw away medicine as its practiced today -- start over, reset, reboot, and say: "What matters is you, the individual. Your data." And if I start you on statins, I want to know if your genomics are going to put you at diabetes risk, or myopathy risk, or does your genome say you'll benefit? I only care about your data, which I've never had before.

You have talked about the need for a consumer health revolution to drive this change. When can we expect this to happen?

It's in its nascent phase, but it is happening right now. I think the consumer-savvy base is waking up. There is a reset here. The digitization of human beings will make a parody out of doctor knows best. We need partnerships. We need physicians working with and guiding individuals. Each individual will have a much more precise view of himself or herself biologically, physiologically, anatomically, to work in partnership with physicians.

This article available online at:

http://www.theatlantic.com/health/archive/2012/03/destroying-medicine-to-rebuild-it-eric-topol-on-patients-using-data/254215/