Personalized Medicine: Back to the Future

How a return to old style medicine represents the new trend, by Scott Shreeve

The personalization of medicine is typically thought of in a genetic sense, wherein people are customizing medications and therapies based on your individual genetic profile: the ‘right treatment for the right patient at the right time.’ Most consumers assume that right/right/right is already happening, and consider personalized medicine to be a type of practice delivery style, where the physician knows the patient’s social and demographic context, and the correct diagnostic or therapeutic approach given the patient’s preferences that have been learned throughout the development of their relationship.

Old-fashioned care

The only physician with whom I have ever had this type of relationship was Dr. Richard Jones, who took care of me between the ages of six and 21. 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 see us at a moment’s 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, a compassionate clinician, and very efficient with his time and practice. More than any single factor, Dr. J influenced me to go into medicine, because of the significant impact 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.

Modern reality

That was not the world I would find years later when going to medical school. The late nineties represented the first major backlashes against both the nationalization of health, as well as the oppressive managed care regimes. The physicians who trained me and my classmates were angry and 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 seven to 10-minute treadmill, a procedure-focused, and RUC-enhanced schema that perverted the primary care practice style that has been shown repeatedly to increase healthcare value (references).

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. The problem of increasing price has been compounded by only marginal changes in the overall health ‘outcomes’ of many primary care related diseases.

Change is coming

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 mis-incentive 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 healthcare delivery reform, and we are seeing a return to when becoming a primary care provider meant delivering preventive care and wellness versus the disease care that passes off as ‘modern’ medicine.

It’s the ‘going green’, renewable wave as applied to healthcare. The first wave of hip new doctors, now better equipped 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 now reinvigorating the entire field of primary care which has unfortunately languished for decades (though not for a shortage of solid physicians).

When added to 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 (RNs, NPs, 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.