Those virtual analyses are becoming the wave of the medical future. JL
Ron Winslow reports in the Wall Street Journal :
For many physicians and their patients, the pandemic triggered a disruption in one of medicine’s most common encounters—and, through virtual visits, provided an early glimpse of the physical of the future. An explosion of advances in digital technology, imaging, gene sequencing and artificial intelligence will likely transform the physical into an even more virtual experience. In five to 10 years, “I’ll be able to do the same quality of physical exam out of the office as if you were right in front of me in the office.”Shortly after his office closed in the early months of the pandemic, Paul Hyman, a primary care physician in Brunswick, Maine, scanned a printout of patients who were scheduled to see him in the next 30 days. Many were due for an annual physical exam, which by definition seems to require an in-person visit.
“You had to decide for every single patient how you’re going to provide care for them in a way you never had before,” he recalls. That prompted him to ponder the role of the physical itself: “What would happen if I delayed it three months, or didn’t do it at all?”
For Dr. Hyman and many other physicians and their patients, the pandemic triggered a disruption in one of medicine’s most common encounters—and, through virtual visits, provided an early glimpse of the physical of the future.
An explosion of advances in digital technology, imaging, gene sequencing and artificial intelligence will likely transform the physical into an even more virtual experience. In five to 10 years, says Michael Blum, a cardiologist and chief digital transformation officer at University of California San Francisco, “I’ll be able to do the same quality of physical exam out of the office as if you were right in front of me in the office.”
Each year, about one in five adult Americans undergoes a routine physical in a doctor’s office, according to one estimate. Doctors take their family history, check blood pressure, heart rate, blood markers and body for signs of disease and, ideally, assess their mental outlook and discuss preventive screenings and the adoption of healthy living habits. An important benefit for many patients and clinicians is the chance to develop a trusting relationship to call upon if and when serious medical problems arise.
But the physical’s own health, especially for patients without symptoms, is in jeopardy. Its primary device is a 200-year-old tool called the stethoscope that studies show many doctors lack the skills to use effectively. Checking blood pressure and other health markers one day a year provides a snapshot that may not reflect a person’s everyday life.
“The data we get from an annual physical is not that robust,” says Geoffrey Tison, a cardiologist at UCSF.
Many doctors say insurance company pressure to make visits more efficient, as well as the need to sit at a keyboard to add data from patient interviews into medical records, render the exam perfunctory, rushed and unsatisfying for doctor and patient alike.
Dr. Hyman found benefits in virtual visits, but, as he wrote in a recent essay in JAMA Internal Medicine, he lamented the loss of human touch.
Bringing more technology into the physical could create more distance between doctor and patient. But researchers who are developing tools and strategies for digital medicine see opportunities for improvement for the exam.
Mayo Clinic, in Rochester, Minn., has started sending laboratory kits to patients in advance of their physicals. Patients, especially those who live far away, can get blood drawn at a local clinic and send it back for standard lab and genetic analyses and discuss results with their doctors virtually. The future, says Carl Andersen, medical director of the clinic’s executive health program, is “bringing healthcare to patients where they are as opposed to asking them to come in.”
Mayo eventually expects to gather additional patient information remotely via smartphone and smartwatch apps, wearable sensors and blood pressure cuffs that enable monitoring of such health indicators as blood pressure, blood oxygen levels, physical activity, heart rate, heart rhythm, blood sugar and sleep quality. Doctors elsewhere have begun adopting this strategy; some experts believe it is poised to fundamentally change how the physical is done and could prompt patients to engage more proactively in their health.
“When people start using a smartphone to monitor their blood pressure, they become experts at managing it,” says Eric Topol, director of Scripps Research Translational Institute in La Jolla, Calif. Maybe “it’s only a problem on Monday morning when they go back to work.” That finding wouldn’t emerge in a once-a-year visit, but it opens options for a patient other than a prescription for blood pressure pills.
Digital stethoscopes are available that allow doctors to check heart and lung sounds remotely. Dr. Tison and his colleagues at UCSF have developed a technique using a smartphone camera and flashlight that can detect a biomarker of diabetes in patients without a blood draw. Mayo doctors have tested an algorithm that can reveal heart weakness from data obtained in an electrocardiogram long before symptoms of heart failure, heart rhythm irregularities or cardiovascular disease arise.
“We’re in the messy adolescence of this experience,” says UCSF’s Dr. Blum. “The technology in 10 to 20 years’ time will look nothing like the technology we have now.”
DNA is poised to become part of the routine physical too. As part of its blood analysis, Mayo will soon offer liquid biopsy tests, which look for evidence of cancer in DNA fragments that even early-stage tumors shed into the bloodstream. The test will search for many more tumor types beyond the screens performed for breast, lung, prostate and colorectal cancers as recommended in current health checkups.
Geisinger, a healthcare system in Danville, Pa., is piloting a DNA screening test in routine physicals that targets some 60 known disease-causing mutations—including the BRCA1 and BRCA2 genes associated with breast and other cancers and a mutation linked to a potentially fatal heart-muscle disease called hypertrophic cardiomyopathy.
nitial results show the effort has detected a culprit mutation in 2.1% to 2.6% of about 130,000 patients, Geisinger says. Genetic counselors help patients and their doctors interpret positive findings and map strategies for managing risk of the diseases, says Christa Martin, Geisinger’s chief scientific officer.
Geisinger is also developing algorithms to mine its electronic medical records. One aim is to unearth patterns associated with early development of heart disease and other ailments that might offer insight for doctors assessing a patient’s risk as part of a health checkup.
Plenty of obstacles loom on the path to the physical of the future. Chief among them is managing the deluge of data already threatening to overwhelm the healthcare system. AI and machine learning advances will be necessary to find important signals in the sea of noise that streams in from digital devices and gene sequencers, as well as minimize the chance such signals are false alarms that lead to unnecessary and costly additional tests and procedures. AI algorithms will need validation to make sure they are stripped of bias and provide information relevant to diverse populations.
Doctor training, insurance reimbursement and regulatory support, policies to engage underserved patients, and development of evidence to vouch for the usefulness and cost-effectiveness of digital approaches will also affect any transition to a new kind of physical.
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Quick, widespread adoption is unlikely. “Medicine is so ritualistic, so sclerotic,” Dr. Topol says. “The number of things that have changed like this are few.”
In any event, UCSF’s Dr. Tison suggests a more dynamic approach to the physical lies ahead: Doctors will provide, say, monthly electronic reports to patients on metrics such as blood pressure, heart function, blood oxygen levels and weight, based on the data stream from digital devices. Unless an abnormal signal turns up, in-person exams—with the hands-on touch doctors and patients value—could be set for every two or three years.
AI-assisted integration of the patient’s medical history, monitoring data and personal genome and microbiome, run against research in the medical literature, may one day be the basis of such visits. The hope is that it would enable a more personal conversation between doctor and patient to set up or maintain strategies for healthy living.
Dr. Topol, an advocate of virtual and digital medicine, says having a trusted clinician who takes time “to listen to your stories and reinforce the good things you’re doing, it can be a precious connection.” He adds: “But that’s something that isn’t easily quantified.
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