Modern Medicine, Mired at the Line of Scrimmage

What if football were more like modern medicine? Perhaps the only way to advance down the field would be to renounce all progress to date and start again each time at the 20-yard line. You never get to build on your prior gains. That seems a dubious game to me.
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Modern medicine has some things in common with football -- or maybe I just have the Super Bowl on the brain. Both, it seems to me, tend to foster our occasionally-overinflated hopes, leaving us at times to contend with a relatively, well, deflated reality.

Both are team sports, advancing courtesy of collective effort. And by and large, progress in each is predicated on prior progress. There is, in football, the occasional kickoff return for a touchdown, or a Hail Mary reception -- and in biomedicine, the occasional "Eureka!" although most of those tales prove apocryphal on close inspection, Newton's apple included. But in both, advance is generally achieved one arduous set of downs at a time.

Now, imagine if instead, football were more like biomedicine. Hold that thought, please -- we'll get back to it. First, let's move the ball down the field.

There is value, to be sure, in advancing a "precision medicine" agenda, a priority affirmed in the president's recent State of the Union address, and one garnering unusual bipartisan support. The proposition seems closely related to recent press highlighting new efforts to find genes that protect us from prevailing maladies.

But I confess I had some misgivings just the same. I'm sure that every other species has substantial inter-individual genetic variation, yet we seem to bank on the biological commonality of a species in how we care for them. Dogs, for instance, get dog food; cats get cat food; and horses get oats and hay. Biological commonality at times extends well beyond the bounds of just one species. Tropical fish, for instance, are many different species; yet it's tropical fish food for the whole lot, if you happen to have them in an aquarium.

I am by no means suggesting that our interindividual variations are unimportant; their importance is self evident in innumerable ways. Nor am I suggesting reliance on standard-issue sacks of "Homo sapien" food, perish the thought. I'm not even asking us to get in touch with our inner fish.

But I am saying that we, too, as members of a common species are biologically more alike than different. And the pursuit of knowing what we can do about what differentiates among our metabolisms should not be at the expense of putting what we know about what we have in common to good use.

That was pretty much the sentiment expressed in a column in today's New York Times, written as a precautionary rejoinder to the fast-track enthusiasm for the promise of precision medicine. The author, a physician at the Mayo Clinic, suggests this enthusiasm is misplaced and apt to leave us disappointed. Certainly that proved true in the early days of the genomic era, recently subject to an about face accordingly.

This also recalls another recent column, by Dr. Ezekiel Emanuel, suggesting abandoning the annual physical exam. While the traditional version of the physical exam is certainly obsolete, there is a real risk in this suggestion of tossing out the baby with the bathwater -- because that encounter may be the only time for doctor and patient to meet other than at a time of crisis. Imagine, then, a world in which at such times of crisis, we have ever more perfect knowledge of a person's genome, and ever less knowledge of that genome's person. Call me a humanist, but that seems fraught with peril to me.

Precision medicine seems to call for a considerable allocation of money to learn things we don't yet know. I support that in principle; it's a classic example of investment and the promise of return.

But a case was made just this week in the New York Times that the return on investment for confronting the scourge of childhood poverty in the U.S. would be nothing short of dazzling -- and that's just in monetary terms. Poverty is a potent driver of diverse miseries, including much increased likelihood of the very diseases we would need precision medicine to treat more effectively.

Similarly, we have a robust body of knowledge about lifestyle practices consistently shown to slash rates of chronic disease and premature death by 80 percent. This reliable knowledge in no way obviates the need to ask new questions and generate new answers. But the pursuit of what we don't yet know does not preclude effective use of what we do, either.

And yet, it does seem to be playing out that way. Even as we contemplate major new financial allocations to precision medicine, childhood poverty is left to languish. My friend and colleague, Dr. Derek Yach, and his co-authors recently pointed out that preventive medicine, despite its formidable and accessible promise, garners only a tiny, non-corresponding fraction of NIH biomedical research dollars. A preferential focus on learning what we don't know does, indeed, seem to hinder action based on what we do.

Call that precision if so inclined, but it seems a lot like procrastination to me.

Or, with the Super Bowl on my mind, like a very odd game of football. What if football were more like modern medicine? Perhaps the only way to advance down the field would be to renounce all progress to date and start again each time at the 20-yard line. You never get to build on your prior gains. That seems a dubious game to me.

And yet there are signs that's the playbook of modern medicine. For instance, I conducted the following exercise for purposes of this column. I searched Pubmed, the vast, online library of peer-reviewed biomedical publications, for papers with "chronic disease" in the title. That is, admittedly, a very simplistic search -- but I thought it would suffice for my purposes. I simply wanted to see the publication trend over recent years. I used five-year increments, ending with the most recent full year, and here is what I retrieved:

1994: 575 papers

1999: 831 papers

2004: 1,430 papers

2009: 2,657 papers

2014: 4,190 papers

Taking this exercise just one step further, here is the percentage increase for each entry relative to the one before:

1999: 45 percent

2004: 72 percent

2009: 86 percent

2014: 58 percent

So, in general, not only is the fund of published knowledge about chronic disease growing dramatically, it is apparently growing, for the most part, at an accelerating rate. And yet, we have a global epidemiology study, overseen by the Lancet, and representing much the same period, showing an increasing burden of chronic disease. This isn't exactly proof of a failure to use what we know, but at the very least it makes that concern an urgent one, deserving of scrutiny.

Whatever the potential benefits of "precision" medicine -- whether we will hit the moon when shooting for it, or miss completely -- how can it make sense to hope for a possible boon in the bush while squandering the one already in hand?

Precision is good, but procrastination is not. We should learn what we don't know, but not at the expense of using what we do. Otherwise, it's a disappointing game with lots of movement, but little progress -- forever mired at the line of scrimmage.


David L. Katz, MD, MPH, FACPM, FACP lives in New England, and is rooting for the Patriots. Just the same, he's not so sure the Seahawks should let them bring the balls, or the guacamole for that matter.

Director, Yale University Prevention Research Center; Griffin Hospital

Editor-in-Chief, Childhood Obesity
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