November 28th, 2018
What’s the biggest problem in health care today? The shortage of primary care clinicians? Rampant overuse and waste? The lack of investment in public health and social determinants of health?
No, the real problem in health care is that there isn’t enough technology involved, say the founders of Forward, a health care startup that just opened its newest clinics on the east coast. In a recent video on Cheddar (a business, tech, and culture news site), Forward CEO Adrian Aoun explains why their model represents the “future of healthcare.” In the video, Aoun shows off the “tons and tons of technology” at Forward’s newest clinic, including heart scanners, body scanners, skin scanners, and DNA sequencing – all of which “give us a better insight to what’s going on with your body,” he says. The video sparked an interesting twitter conversation between investors excited about the expansion of Forward and doctors who were more wary.
The hope for high-tech scans and DNA tests for primary care is that we will be able to get to know our bodies better and prevent illnesses before they start. However, as we wrote in a previous blog about Lab 100, these tests are as likely to expose people to overtreatment as they are to prevent illness. Here’s why:
If we all get regular heart scans, skin scans, and tests of every other body part, there’s no way we would miss any abnormalities, right? Unfortunately, for low-risk people without symptoms, getting tests like electrocardiographs, mammograms, cardiac stress tests, and many others are more likely to cause harm than good. If all of our tests were 100% accurate, they would be great to determine whether or not people have certain conditions, but they are not completely accurate. Even with 90% accuracy, these tests generate large numbers of false positives and expose many people to overtreatment.
For example, screening low-risk adults for atrial fibrillation would require 10,000 people screened to prevent one stroke, but 800 of those people would get a false positive result (If Afib is present in 2% of patients, then 8000 do not have Afib, and 10% of these get a false positive result). And there is no clinical evidence that shows that treating asymptomatic Afib with anticoagulants improves outcomes for these patients.
Both doctors and patients overestimate the accuracy of tests and screenings, which often lead to false positives, overmedication, additional testing, and other unnecessary treatments, not to mention stress and additional financial costs. (For more on how many of the tests doctors do “just to be safe” end up creating more problems for patients, read Dr. Dan Morgan’s brilliant Washington Post op-ed about the harm of unnecessary tests.)
Tech industry to medicine: WE WILL GENERATE ALL THE DATA! YAY!!
Docs: What do I even do with this?
— Christina Farr (@chrissyfarr) November 14, 2018
The idea of fully understanding our bodies by looking at every gene in our DNA is very tempting. Genetic testing can tell us our risk factors for certain diseases and atypical responses to certain medications, which sounds great. But in practice, genetic testing in primary care has not been shown to benefit patients. In a randomized controlled trial published in the Annals of Internal Medicine last year, patients that had whole genomic sequencing compared to just a family history did not result in any new findings or changes in medication management. And the physicians participating in this trial received several hours of training in genomic medicine, so they were more knowledgable than most doctors.
Why wouldn’t genomic sequencing help patients? Because knowing one’s risk of a disease is unlikely to change your current treatment or behavior. For example, if a patient shows an elevated risk of heart disease in their DNA, a doctor would likely tell them to eat a healthy diet and get regular exercise, advice that could be given to every patient. Knowing your risk for certain diseases might even increase stress, especially for diseases like Alzheimer’s for which there is no effective treatment yet. And though some say that knowing one’s risk of future disease is a powerful motivator for changing one’s lifestyle, this isn’t actually born out in studies of people who get tested.
In the Cheddar video, Aoun belittles the conventional history-taking process, saying, “Today you go to a doctor, you sit there and tell them stuff and they almost ‘divine’ the answer…like a modern fortune teller.” What Aoun misses is that taking a detailed history and letting the patient explain their concerns is one of the most important things doctors can do to understand what’s going on with the patient.
As Dr. Stephen Martin, associate professor of Family Medicine and Community Health at the University of Massachusetts Medical School, explained in previous interview about diagnosis:
“Listening to patients is where we learn a great deal about the arc of the symptoms they’re having, the context and severity of the symptoms, what patients are concerned about and why. You can notice and examine symptoms like rashes, ask detailed questions about where patients traveled recently, ask them about other potential stressors in their lives. A CT scan doesn’t have the answers to these questions.”
Also, a patient’s health depends on much more than their physical state, according to Dr. Joachim Sturmberg, associate professor of General Practice at Newcastle University in Australia. Physicians often have to understand a patient’s mental, emotional, and social experiences to put their physical symptoms in context.
Aoun isn’t wrong that health care needs a drastic overhaul. In a recent profile in Business Insider, Aoun argues that it’s not just tech but preventive care that’s missing from the health care system. It’s true that our health care system is much more focused on treating ailments than preventing what causes them. However, the prevention part goes beyond “catching diseases early,” it’s about giving people access to the basic building blocks of health — fresh food, stable housing and income, and freedom from toxic stress. Our country’s poor investment in social determinants of health cannot be solved with more scanners.
Our country’s poor investment in social determinants of health cannot be solved with more scanners.
That’s not to say that the Forward model is all bad. People are increasingly craving a more simple way to engage with the health care system and get more time with their clinicians. The membership model of Forward and other “concierge” clinics provides easy access to clinicians and plenty of time to talk with them, which is very valuable. However, this can also be accomplished more affordably, as advocates of Direct Primary Care have shown. The leaders of Forward likely assume that they can charge more for giving patients more shiny technology, but it’s doubtful this extra “benefit” is even a benefit at all.
If the leaders of Forward want to change the future of medicine for the better, they could establish neighborhood primary care clinics, invest in social determinants of health, or make a better electronic health record (please!). More of the same tech in primary care is not the answer.