In every issue, we interview experts from the Private Medical community, exploring the latest insights and questions about our everyday health. This month, the tables are turned on Private Medical founder Dr. Jordan Shlain as he takes questions in a discussion panel New Healthcare Normal: Precision, Anywhere, Whole Person.
Joining Dr. Shlain are Dr. Joseph Kvedar of Mass General Brigham and professor of dermatology at Harvard Medical School and Dr. Thomas Insel, a psychiatrist, neuroscientist, and former director of the National Institute of Mental Health, who in 2022 cofounded Vanna Health to address serious mental illnesses. The topics discussed include new developments in precision medicine, an exciting frontier that tailors healthcare strategies to each person’s unique attributes. Read an adaptation of Dr Shlain’s contribution to the discussion below, then listen to the entire conversation at New Healthcare Normal: Precision, Anywhere, Whole Person. Thank you to the Intel Alumni Network for hosting and sharing this talk.
This excerpt has been edited for brevity and clarity.
What is precision medicine and how is it different from the way we have traditionally practiced medicine?
There’s no evidence for evidence-based medicine when we’re dealing with an individual because evidence is based on populations. If we look at the Gaussian distribution of a population, one could be in the middle of the curve and another one could be way out there on either side. How do you know which person in the population we’re trying to get to specifically? Evidence is a really good guide to tell us what will work for 80 percent of the population but not necessarily the other 20 percent. Precision medicine tries to figure out which person sits where on that distribution and what is the efficacy of any diagnostic or the therapeutic pre-test probability.
What is the difference between precision medicine and personalized medicine?
Let’s draw on an analogy: think about how we manage our financial assets. How will we balance the risks of the stocks and bonds in our portfolio? In the same vein, our bodies are a portfolio of risks: we’ve got cardiovascular risk, mental health risk; then mix in metabolic risk and environmental risk. There are lots of risks, so how do we quantify them in a way that enables us to manage them?
Importantly, I can tell each person what their risk profile is, but risk tolerance is a completely different facet of the conversation. If someone doesn’t care or if they care a lot, that’s going to change how I work with them in trying to develop a strategy for their health. Specifically, I will review the newer tests. For instance, GRAIL provides a cancer test that has been available for about a year and a half, and is continuing to work its way through the scientific community.
It is designed to detect different cancer types by looking at DNA in the bloodstream and reconstitutes those DNA fragments with artificial intelligence and machine learning. So, this allows us to identify, for example, a fragment of a prostate cancer or a breast cancer gene.
Can you give an example of what precision medicine looks like in your practice?
About a year and a half ago, a 38-year-old male joined Private Medical under my care. He came in a little overweight, with diabetes plus other issues that we were going to try to tackle. His grandmother and his mother both died of gastrointestinal cancer in their 50s and 60s.
This member was concerned about this family medical history as he was planning to start a family. I told him about this new test which costs about $1,000 and is not reimbursable by insurance yet since the data is not all there. He did the test which showed he had colon cancer. But this could be a false positive, which of course happens. I then ordered a Cologuard stool test which was also positive; this was followed by a colonoscopy which was also positive. The member underwent major surgery, then chemo radiation. Two years on, he is cancer-free.
First of all, this fellow may not have gotten a colonoscopy until he was 45 if we had followed the recommended age for people to get their first colonoscopy. Maybe he would have done this at 40 because of his family history. In any case, it was entirely possible that this person would have died before his first colonoscopy because it could have been too late to treat the tumor effectively. This is precision medicine.
What is personalized medicine? How is it different from precision medicine?
Personalized medicine was me listening to this member and offering him that test because he really cared about his health.
Personalization is “what matters to you?” The house of medicine is always asking: “what’s the matter with you?” I think the house of psychiatry and mental health has always asked people “what matters to you?” Rarely do people get a call from their internist. Since they don’t expect calls from us, when we start talking they realize I am 70 percent doctor, 15 percent psychologist, 10 percent rabbi, four percent bartender, and one percent friend! Yet people want us to reach out and communicate. I don’t want to be their friend but I want to be someone with whom they can discuss things openly. It boils down to having a relationship built on this implicit and explicit trust.
Health is all about what people can do for themselves to keep healthy. Healthcare is tapping medical experts and outsourcing this sense of urgency. That’s a very scary thing to do. If people can find a partner who can help them develop a strategy and talk to them about tests and screenings, it can go a long way to help them reduce their fear and anxiety. I think that’s personalized medicine.
Precision medicine is having a degree of precision in our strategy so we don’t have to go through trial and error with five different treatments before we find the right one – and one that works the soonest because my goal is to get the best outcome the fastest.
People are often concerned that they’re going to die or experience other poor outcomes because their doctor made a mistake or didn’t communicate. My advice is get a good quarterback because it’s really hard to be your own quarterback when you’re not a medical expert, as medicine is a very complex realm.