The Promise of Personalized Medicine

If all you want is a doctor who will prescribe you pills, Dr. Neal Carl is not the man for you. If you want to understand the metabolic pathways of your medication, he’ll take the time to explain.

Personalized medicine is the new frontier of healthcare. DNA testing has become so inexpensive that it is now practical to develop wellness regimes tailored to peoples’ individual genomes. Virginia’s biggest endeavor in this field is taking place in Northern Virginia under the auspices of Inova Health System’s Center for Personalized Health. But another approach to health care delivery is taking place here in Richmond. My friend Linda Nash has launched a next-generation concierge medicine business, WellcomeMD, whose physicians treat their patients based on an in-depth analysis of their DNA, gut biome, and a full-battery blood test.

To get a feel for how personalized medicine works, I took up Linda on an offer to have my DNA tested and then meet with WellcomeMD’s Dr. Neal Carl for a consultation. Except in rare instances, genes are not medical destiny. But they do influence our health in many ways, and knowing our genetic proclivities is helpful in crafting an approach to fitness and nutrition.

The testing process is absurdly easy. Visit the WellcomeMD office, take a cheek swab, send it off, and wait ten days for the results. Interpreting the findings, however, requires a background in genetics, proteomics, and metabolic pathways — subjects that few primary care physicians studied closely in medical school. But Carl has immersed himself in these disciplines and how they relate to wellness. After poring through the data on some 20 to 30 “actionable” genes — that is, genes that provide information that can inform us about individual fitness and nutrition — he sat down with me to go through the findings.

I never made it past Introductory Biology in college, so a lot of it was over my head. But here’s what I gleaned from the consultation: Like most people, my genes confer both strengths and weaknesses in the 21st-century struggle for health and wellness.

My genetic profile indicated that my power/endurance response is weighted in favor of endurance. I was never destined to develop a weight-lifter’s physique. I wasn’t genetically predisposed to become the fabled 90-pound weakling, but I was never going to become a Charles Atlas either. Lifting weights could increase my strength, but I’d never develop bulky muscles. Conversely, my body is genetically suited to moving oxygen to body tissues and metabolizing it efficiently. Practically speaking, I’m far better suited to fitness regimes that emphasize endurance over strength.

The genetic test also measures for the body’s ability to detoxify muscles after exertion. I fall in the middle range, suggesting that I needed a day’s break between intense workouts. I also have a proclivity for injury of tendons and ligaments, with special concern for the Achilles tendon.

All this rang true. While I was never a great athlete, I devoted 14 years of my life to serious study of Tae Kwon Do, the Korean martial art. On the side, I ran, lifted weights, and did aerobics. I was never the strongest, certainly not the fastest (Carl confirmed that I lack the fast-twitch genes), nor the most flexible, but I did have the capacity to finish grueling hour-and-a-half workouts while others were hugging the floor. If I could survive the first 45 minutes of a fight, I could definitely kick the other guy’s ass!

Without the benefit of medical coaching, I have fallen into a fitness regime consistent with what my body was telling me. These days, I sporadically lift light weights and do one or two bouts a week of intense half-hour cardio. My efforts at consistency are bedeviled on and off by minor problems with rotator cuffs, pulled muscles and once, in an ill-fated fling with barefoot running, a pulled tendon in my foot that left me limping for weeks. All of these traits were consistent with my genetic profile.

As for nutrition, my genes don’t put me at risk for obesity, but just gaining 10 to 12 pounds over my ideal weight does put me at risk for pre-diabetes. I have a metabolism that makes me gain weight more readily by consuming carbs than fat. I’m salt sensitive (which may help explain my hypertension), and I have a heightened cancer risk from eating charred meat — which is a major bummer, because half the meals I eat consist of grilled beef or chicken. This information is useful because, evidently, I have not naturally gravitated in life to a nutritional regime consistent with my genetic endowment. Things must change. There will be more broccoli and brussel sprouts in my future.

The body is an incredibly complex organism, and a handful of genes don’t tell the whole story. To get a full, rounded picture of my health, Carl also would test my gut biome. Intestines are a “second brain” loaded with neurotransmitters, he says. When your intestinal bacteria aren’t happy, you aren’t happy. If I were a patient, he also would get an in-depth blood panel looking at dozens of markers — far more than the normal primary care physicians would track. And he would integrate all that data into a holistic understanding of my health that encompasses exercise, nutrition, stress and sleep.

New medical model. Managing a patient’s wellness at this level of understanding is time-consuming, and primary care physicians, who typically have a roster of 3,000 patients, cannot do it. The business model of WellcomeMD calls for Carl to oversee only 300 patients.

Nash founded PartnerMD, a successful concierge medicine practice, before leaving the company selling out her interest several years ago. As soon as her non-compete clause expired, she was ready to roll out what she calls “concierge 2.0.” The old model allows doctors to spend more time with patients and give them more holistic care. But WellcomeMD pushes the envelope of medical practice.

“Genetics testing has to be part of concierge medicine going forward,” says Nash. “It really is a different model. For people who want to delve deeper into their genetics, their stress, their sleep, we’ll have more time and more advanced tools. Under the traditional model of medicine, there is no possible way to do this.”

Carl, who practiced general medicine at Chippenham Hospital, found the traditional medical model frustrating and unsatisfying. He saw on average about 25 to 30 patients a day, whom he had to move through in an assembly-line process. He focused on getting their “numbers” to look good — numbers for blood pressure, cholesterol, blood sugar, and the like.

“As it played out, a percentage of the patients didn’t feel that well. Many were on several. Even with good numbers, they still had bad events,” he says. By way of comparison, he notes that television broadcaster Tim Russert had a “normal” cholesterol panel, but he had an underlying cardiovascular disease that his doctors didn’t catch until he had a fatal heart attack.

“We were putting Band-Aids on things and not getting root causes,” Carl says of his former practice. “There had to be a better way to practice medicine.”

Many medicines have side effects, which require additional medication to treat the side effect. Now he combines personalized data with vitamin supplements and a holistic approach addressing what patients eat, how they sleep, and how they exercise to wean them from medication. Instead of treating pharmaceuticals as a magic bullet, the first option, he sees them as the alternative of last resort. He has succeeded in getting “dozens” of patients down from six or seven medications down to one or two, he says.

Carl concedes that he is “ahead of the science” in some areas. Based upon a theoretical understanding of metabolic pathways, vitamins like B6 and B12 should help patients deal with certain types of depression. But who has the incentive to conduct multimillion-dollar clinical trials to prove the efficacy of inexpensive vitamins? No one. On the other hand, the risk and cost associated with trying vitamins are very low. So, why not explore that option in treating patients?

Ideally, dispensing medicine should be more sophisticated than saying, “Your numbers don’t look good, here’s some medicine.” By limiting his practice to 300 patients, he has the time to measure, test, and measure again, before and after prescribing a medication. He also has the time to act as coach and educator to get patients more engaged with managing their health.

“It’s much harder to practice this way,” says Carl. “But I enjoy it.”

Wave of the future? It is common wisdom that the U.S. healthcare system spends far too much money on treatment and not enough on prevention. It is less commonly observed that much of the money spent on prevention — such as cancer screenings — is wasted as well. Human beings are so variable that preventive medicine that makes sense for one doesn’t necessarily make sense for another. Clearly, personalized medicine has the potential to achieve great savings and spur better outcomes.

But concierge-style personalized medicine is expensive. Wellcome MD charges a $2,500 annual fee over and above the cost of medical insurance and co-pays. Although personalized medicine provides them an option they didn’t have before, Americans with modest incomes may not be able to afford that extra fee. Moreover, the United States suffers from physician shortages. Medicaid patients find it difficult to find a doctor as it is. If enough physicians reduce their caseload from 3,000 patients to 300, this medical model could precipitate a social crisis.

But Nash is confident that WellcomeMD will be a net positive for the world. Personalized medicine is the wave of the future, she says. Too much medicine is reactive medicine, fixing the body after it’s broken. Personalized medicine is proactive medicine, helping motivated people manage their wellness and, ideally, reducing demand for the costly chronic medical conditions that make U.S. health care so expensive. The up-front cost may be more expensive. But that’s the way it always has been with new technology from laptops to smart phones. Affluent customers support the pioneers. Over time, as the early practitioners learn more and share their knowledge, costs come down and everybody wins.

Plus, there are benefits that can’t be measured with dollars and cents. “We want to help people live longer, more productive lives and live better,” Nash says. “My husband and I want to be hiking inn-to-inn in the Alps in our 80s, and we want to use every tool available to achieve that goal.”

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11 responses to “The Promise of Personalized Medicine

  1. Here’s some interesting statistics:

    Life expectancy

    Fairfax Virginia – 83.7
    Japan – 83.7
    U.S. 79.3
    Cuba 79.1
    McDowell , WVA 70.3

    30 other countries beat the US on Life Expectancy , many of them, including Canada and even the UK are said to be “govt-provided” and rationed.

    We won’t fix our health care with concierge medicine – and I seriously doubt that it will lead the way in providing a better model of health care.

    I’m all for people who have the finances to seek the best medical care they can – including concierge if that is their wish but our problem can be seen
    in the lift expectancy of counties like McDowell in WVA. Concierge medicine is not going improve the life expectancy of those folks – not because it would not … it’s will it ever be available to them?

    I still say that the way for this country to improve the health of people is to have electronic medical records – ESPECIALLY for the folks that need govt assistance… it’s imperative that whatever provider is providing service to an indigent person that they do have a complete medical history… to prevent mistakes to prevent duplicative tests but right now – we pay different doctors to treat patients as if they are the first doctors to do it -and there is no prior medical history.

    Here’s the bottom line. The people in this country who can afford good medical care – live as long as folks in Japan. The question is – what is the “model”? Is it the same model that Dr. Nash found stifling and not good?

    I strongly suspect the people in Fairfax get … fairly traditional medical care but from pretty good Doctors and practices… something the folks in McDowell WVA do not have and certainly not the folks in rural areas where hospitals are closing.

    Should MedicAid start providing Concierge doctors to those folks because it’s got a better ROI? eh… probably not. What should they get instead – right now?

  2. In terms of models – why not adopt those that already do provide lower costs and longer longevity?

    here’s another pretty interesting table that comes from a list of the counties with the highest life expectancy:

    1. Summit County, Colorado 86.83 79.18
    2. Pitkin County, Colorado 86.52 78.81
    3. Eagle County, Colorado 85.94 77.21
    4. Billings County, North Dakota 84.04 79.44
    5. Marin County, California 83.8 75.66
    6. San Miguel County, Colorado 83.73 77.58
    7. Fairfax County, Virginia (and city) 83.73 76.65

    The first number is the current life expectancy. The second number was the life expectancy in 1980.

    so they have ADDED about 5 years to life expectancy in the last 40 years!

    that’s phenomenal!

    Even in the lowest life expectancy counties life expectancy has increased but at about half the number for the highest life expectancy counties in the US.

    so … across the board , life expectancy has increased in the US – albeit at a much higher cost that compared to other countries who pay about half what we pay.

    I was particularly struck by this statement: ” It is less commonly observed that much of the money spent on prevention — such as cancer screenings — is wasted as well.”

    The conventional wisdom is that people in rural areas without access to continuing medical care – die from NOT being regularly screened. So it does concern me that we have a point of view that cancer screenings are a “waste” because we are variable individuals… Some, perhaps most cancers are not detectable without screens… and by the time symptoms are apparent.. the cancer has advanced and will be much more expensive to combat and more folks will die than if it was caught earlier.

    So that idea sticks out like a red flag to me. The opposite seems to be true – that if we had better screens, we’d catch even more people earlier in the progression…

    • Summit County, CO: population density 46 per sq mi
      Pitkin County, CO: 18 people per sq mi
      Eagle County, CO: 31 people per sq mi
      Billings County, ND: 0.7 people per sq mi
      Marin County, CA: 300 people per sq mi
      San Miguel County, CO: 5.7 people per sq mi
      Fairfax County, VA: 2,813 people per sq mi

      “The conventional wisdom is that people in rural areas without access to continuing medical care – die from NOT being regularly screened.”

      5 of the 7 counties on your list couldn’t be more rural. Why are they so long lived?

      I’d suggest that you take a look at the smoking and obesity statistics in the counties you cite.

      Here’s my proposal – any locality in Virginia can vote to receive Medicaid expansion funds so long as they also vote to make the sale or possession of tobacco illegal, impose a 20% surcharge on the sale of unhealthy foods and limit the sale of alcohol to no more than two drinks per person per day through the use of electronic ration cards.

      • Good observation! I think it’s some rural mixed with wealthy counties.

        here’s the thing – you’d penalize the obese and smokers in the rural counties but not in Fairfax where the obese and smokers have access to better health care to improve their lives even if they are fat?

        and if you did what you said on a per county basis – wouldn’t you just encourage black markets?

        • I’m not sure how banning smoking penalizes smokers. Doesn’t it really kind of help them?

          As for Fairfax County, if they voted to take Medicaid expansion money they’s have to implement the same rules as any other locality that took the money.

          Our useless state legislature has the second lowest tax rate on a pack of cigarettes in the United Staes. They then follow up that absurdity by restricting how much localities can additionally tax cigarettes. This is all done so they can keep stuffing their pockets with money from tobacco companies. If the Dems ever get to the point that they can pass the Medicaid expansion I also hope they pass a massive increase in the tax on cigarettes.

  3. Jim:

    If there’s a doctor shortage and this concierge medicine approach reduces the roster of patients per doctor from 3,000 to 300, doesn’t that just make things worse.

    Also, with due respect to doctors, how much of your genetic / health / lifestyle analysis could have been performed by software if the FDA would speed up its approval of software as a diagnostic device?

    • The way to get REAL competition in health care is to allow anyone to go to any doctor without fear that they’d be leaving their medical records behind with the prior providers or have to pay to get hundreds of pages copied that no one would read anyhow.

      You need your records in electronic form – and for it to be “portable” like your 401K is.. so you can the option to choose who to go to.. and if they are not right, then move on.. or better yet – go to several and all of them are working off the exact same medical history…

      so I’m talking about MORE than just electronic medical records. I’m talking about medical records that can be read and searched by any medical provider.. i.e. “inter operable”.

      What that means is that when Doctor A adds an entry… Doctor B can “see it” with his software – as opposed to the file being little more than a text file in electronic form.

      so, for instance, a doctor could search for all your glucose levels for as many times as you’ve had it measured so if he/she was trying to see if you were trending towards diabetes.. they could see that trend in your blood labs over time.

      Compare that to a doctor that orders the test and sees a number and has no idea how that compared to the previous labs or labs 5 years ago.

      That would be my idea of how a “personalized” doctor coincerge would actually have to work. It would be far more than looking at your genetics. It would be looking at your complete medical history and the trends… and you cannot do that by first time examinations and no knowledge of your prior labs and tests…etc…

      In fact, most folks who have been to a new doctor lately know the drill. You are given a clipboard and asked to pencil in your Medical History. If you have spent 50 years on this earth – and you’re trying to do that from memory…good luck.

      Anywhere where you do not have a regular doctor or have switched doctors or are seeing specialist beyond your own primary care.. you need these records and they need to be complete and accurate.. and they are neither if you are jotting them down on a clipboard from memory prior to your appointment.

      you want better care , cheaper care, longer life expectancy…you need inter operable electronic medical records.. and yes.. they should be encrypted and you’re the one with the “key” to unlock.

      • I agree. However, I thought the Obama Administration successfully pushed for Medicare reimbursements to be ties to a doctor’s use of electronic medical records. My doctor certainly though he had to implement electronic medical records processing or face a reduction in what he was paid by Medicare. So, he implemented medical records processing. Kudos to Obama on that one. The problem seems to be that the medical records become the provider’s property instead of the patient’s property. My doctor sold his practice to Innova and I can access my records over the internet. However, as far as I know, I can’t download those records to some consumer-based medical records storage site and release them when and if I want to do so.

        Maybe I’m misunderstanding this but I don’t know anybody who has their electronic medical records easily accessible over the internet or on their smart phone.

  4. This idea was in Boomergeddon and while interesting it is unrealistic as it is available only to the very wealthy. It would be interesting if some ideas from the concept can be made applicable to the vast, real world of underserved people but where are those figures?

    • Peter, did you notice the following paragraph?

      “Concierge-style personalized medicine is expensive. WellcomeMD charges a $2,500 annual fee over and above the cost of medical insurance and co-pays. Although personalized medicine provides them an option they didn’t have before, Americans with modest incomes may not be able to afford that extra fee. Moreover, the United States suffers from physician shortages. Medicaid patients find it difficult to find a doctor as it is. If enough physicians reduce their caseload from 3,000 patients to 300, this medical model could precipitate a social crisis.”

      • These comments too relate to our system of health care that closes down community hospitals, likely killing off whole ecosystems of health care professionals in more rural areas that desperately need more not less health care close by.

        Another related issue as to how our elites build systems that covertly steal and illicitly divert public monies belonging to people seeking health care to their own private advantage. This is likely where much of funds came from that were diverted into the UVA Strategic Investment Fund. That is skimmed off (ripped off) most likely from over payments charged to patients at UVA hospital.

        In this regard, recall how UVA hospital was said to be in such desperate shape financial around 2011, the time of the Sullivan firing, yet somehow managed its incredible conversion into a money making dynamo spinning out of nowhere staggering sums of money as if by magic. Recall too how the magic conjuring act seem to suddenly sprout in existence not long after a former John’s Hopkins medical financial expert joined the UVA team as a board member as I recall. Perhaps IZZO may be able to throw more light on all this. Including perhaps where Inova and its ilk suddenly came up from out of nowhere to dominate its scene. What kind of swamp creature are these that can gobble up whole public industries so quickly? While others health care hospitals die off like dinosaurs in the age of meteor strikes.

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