Thursday, November 6, 2008

Nature is so Wrong!

Nils over at SciPhu has decided to stop posting about DTC and his stance. Why would such a great scientist/blogger decide enough is enough? Nature made him do it...Huh? Yes Nature and its eloquent arguments about personal genomics......

From Nils

"I have voiced opinions on this too, but have decided to desist more arguing (for a while) after reading this editorial in Nature biotechnology"

I am going to deconstruct the arguments in Nature right Now!

1. We need to move from late to early diagnosis

It is virtually impossible to conceive of a sustainable form of healthcare that operates as the current systems in industrialized nations do. At present, healthcare is based on the late diagnosis of disease and the division of diseases into a few categories based on some overarching gross similarities. And it firmly places physicians as the central gatekeepers of information.

So this argument says.....That in the current system...

1. Doctors cannot do early diagnosis

2. Patients should be responsible for early diagnosis

3. The current system is not adapting to early diagnosis

Why is this nature argument a fallacy?

1. Doctors have been doing earlier and earlier diagnosis.....Ever heard of Pre-Hypertension or Pre-Diabetes? These conditions are getting detected at earlier and earlier stages, physicians ARE doing a better job of finding this out.....

2. Patients can interpret laboratory tests and should because we don't have enough healthcare providers to interpret the data......Huh? Ok, so I propose that we have 2 levels of care, the one level in places like Harlem where it is an under served community. We have a patient take a blood test and then have the patient interpret the results. Heck we could give them a computer and Internet.......Good luck! Oh and the other system where doctors and other healthcare practitioners decide to practice and deliver care.....Nice argument.....

Patients should not be responsible to defend themselves in a court case because they can't afford an attorney, they shouldn't be responsible to design their own homes because they can't find an architect, Hell, there is even H&R Block for people's taxes.....Why are we trying to cut out healthcare professionals because costs are high? I say costs are high because we don't have enough professionals...instead we have coders and healthcare administrators............Would you expect a patient to interpret a liver biopsy? What about an X-Ray? So why in the hell would you say they should interpret their own genetic information? Garbage argument.....

3. Huh? The system is adapting to early diagnosis and adherence to standards of care. Ever heard of PQRI? What about JCAHO and the preventable outcomes evaluation? The system is working to prevent errors and diagnose early.......Just b/c it's not enough doesn't mean you destroy the system.....

2. To do this we need find ways to utilize the potential unleashed by large scale analysis of genetic-material.

The healthcare of the future, on the other hand, if the technical potential to provide personalized medicine is ever to be realized, will probably require a greatly expanded emphasis on diagnosis and monitoring, early and subtle intervention, monitoring of the impact of intervention, and gradual adaptation of treatment with the evolving physiology, metabolism and lifestyle of the individual.

So this argument says that we don't have enough people to monitor the care of patients, so we scrap that system and put everything in the hans of the patient.....over the internet I suppose. There are 3 things wrong with that.

1. What happens when a patient mis-diagnosis him/herself? What happens when the ignore the "Service engine soon" light? The same people avoiding healthcare now are precisely the ones who have diabetes diagnosed at a late stage, or the patient who comes in 5 days after his heart attack.

2. What's to say the the Internet will motivate that person to change? Doubtful at best.....Patients need professionals to monitor their health....end of system can serve all.....even crazier.....who maintains privacy of that patient?

3. Even crazier....who does a patient sue when the diagnosis is missed???? The system?

Nature's solution?

3. But, the medical professionals and healthcare systems do not currently have the capacity to adequately respond.

Faced with this huge expansion of data on ‘my’ health, it will simply not be affordable to maintain our dependence on medical gatekeepers, whether they are physicians or genetic counselors, without individuals taking a much greater responsibility for their own wellbeing. Whether the medical establishment likes it or not, it will be too cumbersome and too expensive to conduct personalized medicine if all diagnostic-to-therapeutic decisions depend on doctors.

Ok, mythbuster number 3.....the amount of data relevant to a patient's care and health WILL NOT CHANGE THAT MUCH IN THE NEXT DECADE!!!!!

But you could greatly overwhelm the system by introducing bogus bits of information that have absolutely nothing to do with health outcome.....Don't believe me? Did you read the incidentalome written in JAMA. Russ Altman and Zak Kohane (advisors to 23andME wrote this)

Here's the excerpt:

Genomic medicine is poised to offer a broad array of new genome-scale screening tests. However, these tests may lead to a phenomenon in which multiple abnormal genomic findings are discovered, analogous to the "incidentalomas" that are often discovered in radiological studies. If practitioners pursue these unexpected genomic findings without thought, there may be disastrous consequences.

First, physicians will be overwhelmed by the complexity of pursuing unexpected genomic measurements.

Second, patients will be subjected to unnecessary follow-up tests, causing additional morbidity.

Third, the cost of genomic medicine will increase substantially with little benefit to patients or physicians (but with great financial benefits to the genomic testing industry), thus throwing the overall societal benefit of genome-based medicine into question.

They said why are the advising a company which puts all that data out there???? Good question.....

The Sherpa Says: Because the system can't handle the data we should throw out the interpreters of the data????.....Listen.....this isn't Cobol you freaking chuckleheads! This is years and years of scinetifically proven medical physiology, biology, and healthcare which doesn't just get replaced with a better model.......We may Augment....but never completely replace....until the evidence tells us what we are doing is incorrect we shall continue with what we have.


Anonymous said...

When I was told yesterday that Nature had a whole series about personal genetic topics, I was excited. Then I started reading the articles and all the articles basicallly were opinion pieces. I hate that garbage. Bring some facts to an argument and let the facts speak for themselves.

"How to get the most from a gene test" What was the author trying to say again? I didn't get anything out of the article. All I noticed was a bunch of PR stuff.

"Personal genomes: The case of the missing heritability" Another boring article. Just a repeat of what we already know. I didn't see any mention about taking into account ones envrionment when looking at genes for height. A person who is deprived of food won't reach their full height potential no matter what set of genes they have.

You already touched on the other stuff.

SciPhu (Nils Reinton) said...

Steve. Reading yout post I am kinda glad these are quotes I have in my post... ;-)

My own conclusions from this Nature Biotechnology editorial is that we definitely need regulation. But, we should move on from the regulation/no-regulation debate and into the which tests should be regulated and to which extent, discussion - Final remarks on my post: "In my opinion, there is an imminent need to define the subgroup of genetic tests that needs to be accompanied by counseling/medical advice. Group those out sensibly, grade them according to counseling (or medical) importance, and you have a solution."

Oh, and I have a question too: Do you honestly believe that "the amount of data relevant to a patient's care and health WILL NOT CHANGE THAT MUCH IN THE NEXT DECADE!!!!!".

If so, what's all the sequencing going on in PGP, 1000 genome project, Singapore, China, ...., about ?

Andrew said...

I don't like PR flack, but I would say that the actual practice of medicine is more about shuffling junk information than about understanding and manipulating human biology and that's the source of people's frustrations.