Personalized Medicine (pûr’sə-nə-līz d mĕd’ĭ-sĭn)
- The type of sing molecular analysis to achieve optimum medical outcomes in the
management of a patient’s disease or disease predisposition, - Right treatment for the right patient at the right time.
As I have mentioned in several of my posts, I have been working on a couple of health care finance reform initiatives over the last six months. After banging away now for awhile, I am starting to see some emerging ideas that are starting to bring out that old revolutionary feeling of doing something that can have an industry changing impact. The opportunity lies in the ongoing pace of innovation, with new forms of health care delivery, with new models of health care financing, and that fact that eh American public and politicians are slowly waking up to the fact that our health care system is headed toward radical surgery (not the cosmetic kind).
So lets start this out by talking about the personalization of medicine. This is typically thought of in a genetic sense, wherein people are customizing medications and therapies based on your individual genetic profile. Said in other words, the “Right treatment for the right patient at the right time”. However, most consumers already assume Right/Right/Right is happening, and more likely consider personalized medicine as a type of practice delivery style. This is where the physician knows the patient intimately, their social and demographic context, and the correct diagnostic or therapeutic approach given the patient’s preferences that have been learned throughout the relationship. The only physician I have ever had whom I had this type of relationship with was Dr. Richard Jones who took care of me from age 6-21 (when the front office lady finally told me that I “really should find another doctor“).
Dr. J, as he was affectionately called, had a personal interest in our family. Not only did I play football with his son throughout my school years, but he was always available to to see us at a moments notice. He was larger than life in our home – he expertly took care of coughs, earaches, nosebleeds, annual physicals, immunizations, concussions, and nearly every other ailment we could bring to him`. He was an excellent diagnostician, compassionate clinician, and very efficient with his time and practice. As our team physician, I got to know him as a second coach, a counselor, and someone who could console in times of defeat and share the joy of championships. In fact, more than any single factor, Dr. J influenced me to go into medicine because of the significant impact that he had in my life. I looked up to him as a role model, as an advisor, and as a friend. The relationship was time-tested, absolutely trusted, and he represented someone and something that I aspired to be.
However, that was not the world that I would find years later when going to medical school. The late nineties represented the first major backlashes against both nationalization of health (aka “HIllaryCare v1.0”) as well as the oppressive managed care regimes. The physicians that trained me and my classmates were angry, bitter, decrying the loss of the “golden era”, and just plain burned out. The Dr. J’s of the world were being forced onto a 7-10 minute treadmill, procedure focused, and RUC enhanced schema that perverted the primary care practice style that has been shown to increase health care value. The entire E&M coding concept, the fee for service, “do more get paid more” delivery model supported by RUC reimbursement methods (and its 24 out of 29 specialist committee members) has led to a dramatic DECREASE in VALUE (outcomes/price) by dramatically driving up the “price” part of the equation. In addition to driving up price, (which was initially combatted and later retracted through the managed care “spasm”) the problem has been that even with all the increasing costs there has been very little change the overall health outcomes. Research by Wennberg, and books like Overtreated and Crisis of Abundance effectively make the case against the specialist and procedure intensive “Premium Medicine” currently practiced in America.
But all that is beginning to change. Just as data drives discovery, medical evidence can and should drive medical practice. The evidence is showing that our current cultural expectations, third party payment misincentive system, and malpractice litigation environment are creating the perfect storm for healthcare reform. The winds of revolution are being buoyed up by the pioneers of health care delivery reform, and a return to when becoming a primary care provider delivering true health care (preventive care and wellness) versus “disease care” (what is currently practiced) is actually cool. Its the “going green”, renewable wave as applied to health care. I have documented the first wave of hip new doctors, now better equiped through technology to deliver highly personalized care (personal health records, predictive practice analytics, and evidence based treatment sensitive to individual cultural, demographic, and contextual preferences) who are reinvigorating the entire field of primary care which has unfortunately languished for decades (not for a shortage of solid physicians!). When added alongside payment reform (initially beginning as cash payment for services), and ultimately the realignment of incentives (through market forces supported by an appropriate regulatory environment) and reassignment of work tasks (appropriate utilization of physicians and other trained healthcare providers (RN’s, NP’s, etc), primary care has an opportunity to survive in a modified form.
So we are back to where we started 50 years ago. Trusted primary care physicians using technology to delivery highly personalized and effective medicine that their patients value and are willing to pay for – now that’s a future Dr. J could be proud of.
Scott Shreeve, MD 
Current market forces still encourage specialization;the practice of which limits doctors to “parts” oriented solutions as a natural consequence of the myopia that it causes. It also prohibits prevention and relegates doctors to perpetually “looking for cures.” FP is the only specialty that truly has the ability to connect-the-dots and recognize that patients are whole people and finally allow the possibility of prevention as well as recognizing that specialists have been providing advice about what turns out to be the same thing taking place in different body parts. We call them co-morbidities, but they are really often the same thing.