In recent history, America's healthcare industry has been diagnosis-focused, but we didn't start out that way. In the late 1800s, Sir William Osler — who is considered the father of American medicine — said, "The good physician treats the disease; the great physician treats the patient who has the disease."
Between then and now, we've stopped thinking about the patient and started concentrating on the illness.
For instance, by law, the Food and Drug Administration can approve a medication only for a diagnosis, not for a symptom in a particular type of patient. Insurance companies, including government insurance, pay for diagnostic codes. And in academia, careers and reputations are made by researching treatments for ailments, not patients.
This has given us a reductionist and less relevant emphasis; a system of healthcare that's easier to measure and track, but is more expensive and less responsive. Patients are jokingly referred to as "the hernia in room 412" or something equally dehumanizing, yet hernias don't get ill and diseases don't get well; people do.
A system created and once controlled by healers has become more concerned with diagnoses than with patients. Hopefully, though, that's changing with the growth of precision medicine and the vast amounts of medical information we now have the potential to utilize.
Individualization is crucial for real results
When I started medical school, we didn't know which of several different treatments were better for patients with high blood pressure. To study them, researchers placed 100 patients on beta blockers and 100 patients on angiotensin-converting enzyme (ACE) inhibitors and observed which group had lower blood pressure.
The result was that one treatment proved better, but then someone noticed that even in the other group, some people improved. They didn't know why, but ethnicity appeared to be a factor. Sure enough, when the other group was controlled for ethnic background, researchers found that one treatment worked better for one ethnicity and the other for the other ethnicity.
However, there were still people in each ethnic group who didn't respond as expected, because high blood pressure has nothing to do with skin color. Now, through an individualized approach, we can look at a specific patient's ACE enzyme to see whether an ACE inhibitor would be best, regardless of how the patient looks.
National healthcare spending, which reached approximately $3 trillion in 2014, or more than 17 percent of the nation's gross domestic product, suggests we spend more on ineffective treatments than we do on effective ones. Imagine how much more care we could afford if we used all the tools at our disposal to individualize treatment plans and cut back on ineffective care.
Shifting the focus back to healing
The Precision Medicine Initiative, announced by President Barack Obama in his 2015 State of the Union address, marks an important step in the shift toward individualized healthcare. Precision medicine accounts for variations in patients' genetic, environmental, and lifestyle differences to further scientific research and medical treatment. The benefits are already apparent, with large percentages of healthcare professionals reporting positive impacts on patient volume and drug and treatment discovery.
Still, our institutions are largely set in the past, with laws and regulations that appear largely against individualization. The FDA's constraints, for example, make it difficult to treat a specific biological set instead of a diagnosis. The White House's initiative is an important stride, but it's being added to the already existing structure. Instead, we should ask, "Now that we have the tools we have, what assumptions did we make 50 years ago that are no longer true?"
The future of individualized healthcare
The future of precision healthcare depends on having specific treatments according to genetic type. While we now know that diabetes is partly an autoimmune disease and has more to do with individual responses to the allergen than the allergen itself, we need to also know why those individual responses exist.
So with the government running out of money for healthcare and insurance companies covering less of the ride, patients are picking up the slack themselves and prefer to pay for value. They will increasingly look outside the system to find a better bang for their buck, which means more effective individualized healthcare. The groundswell movement will force change from the bottom up, rather than a top-down redesign of medicine.
In achieving truly individualized care, we need to be quicker to accept newer technologies and be willing to change our old ideas in the face of it. The future will be marked by a rising demand for individualized care that truly adds value to the person receiving it. If we don't change now, then private companies will start offering solutions outside the healthcare system, and eventually, healthcare institutions will struggle to adapt to survive.
Dr. Howard Wetsman is an addiction medicine physician and psychiatrist living in New Orleans. He is the chief medical officer of Townsend Treatment Center in Louisiana and is a member of the board of the American Society of Addiction Medicine.
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