The healthcare industry is changing as new models of care and reimbursement emerge. One of these approaches is P4 Medicine. P4 Medicine stands for predictive, preventive, personalized, and participatory. This approach deeply resonates with me because the philosophy is aligned with how I have been developing my medical practice, which is focused on optimizing health and avoiding disease. In my opinion, P4 Medicine is one of the best models for maximizing patient engagement.
The earliest manifestation of P4 Medicine began eight years ago at the Institute of Systems Biology when Dr. Lee Hood, MD, PhD, a physician scientist and creator of the automated gene sequencer, recognized that the application of systems biology to medicine would fundamentally alter our understanding of health and disease. This model has merged three powerful aspects of science and technology:
1. Systems biology (defined as the study of biological systems as collections of networks at multiple levels, ranging from the molecular level, through cells, tissues and organisms, to the population level)
2. The digital revolution (e.g., big data and analytics, wearable technology, mobile technology, etc.)
3. Consumer-driven healthcare (e.g., patient/consumer activated social networks)
One of the most important lessons learned in medical school is how to take a thorough medical history. It is one of the best diagnostic tools available to physicians, but because of insufficient time and over-reliance on labs and imaging, it has been steadily reduced to a less than five-minute interaction with a patient. In my practice, every new patient receives a thorough medical history that includes a family and genetic history. I use this as a predictive tool to correlate with genetic data and to further personalize their health optimization plan.
I’ll use an example from my own life to explain this further. My great grandfather and great granduncle died from colon cancer. My mother did not discover this until she was diagnosed with colon cancer and her mother told her about her family history. My parent caught it early with a colonoscopy and was able to be cured through surgery. As a preventive measure, I am going to get a colonoscopy 10 years earlier. Additionally, I eat a mostly plant-based diet (with some meat and fish) and maintain optimal vitamin D levels because I know these are associated with lower colon cancer incidence.
Along with a medical history, I perform a health optimization assessment where I ask my patients to describe three wishes and three fears they have for their health, as well as three problems they would like to be erased. I ask them to rank their readiness for modifying their diet, practicing relaxation techniques, engaging in exercise, having periodic lab tests, educating themselves about their condition, and making changes to their lifestyle. This assessment helps me personalize their prevention plan to their goals and motivations.
This approach makes them more likely to participate in health behavior change when they are doing what they want to do, rather than just what I tell them to do. I suggest a variety of digital health technologies to my patients to keep them engaged outside of the exam room. For instance, I suggest an activity monitor if a patient is not exercising at all. After they have met their activity goal, we start discussing more exercise options.
One of my patients in his early 50’s has metabolic syndrome and is committed to losing weight. He regularly sends me reports from his connected activity monitor and connected scale to track his progress. We’re also tracking his cholesterol levels and glucose with point-of-care devices he can use in his home. Our goal is to prevent the same cardiovascular disease, which his parent recently experienced. And, by reversing metabolic syndrome, we may prevent a variety of other diseases from emerging. In comparison to healthy patients, patients with metabolic syndrome have a 30 times higher diabetes risk, two to four times higher cardiovascular disease risk, and a two times greater stroke risk.
I have twenty-six year old patients with predictive lab markers of metabolic disease who look like patients in their fifties. They know they should eat right and exercise, but they don’t engage in these behaviors because that advice means nothing unless it is personalized. Doctors used to prescribe food diaries, but now we have apps that we can recommend for nutrition tracking. I don’t usually recommend that patients track their food intake everyday, but instead ask them to track their diet for three days to identify what they typically put in their bodies. Using apps like MyFitnessPal. Lose-it, Cron-o-meter, or SparkPeople can make nutrition diaries even more useful because they also tell you how many calories, macronutrients, and micronutrients a patient has consumed.
I have found that my patients are more likely to be engaged and participate in changing dietary behaviors when my recommendations are backed up with data. So, I take the information from the food diary and combine it with genetics data, micronutrient levels, and fatty acid markers to give them a personalized plan of action. Right now, this is a manual, time consuming, and expensive practice. But, in the future, when we have individual data clouds collected on 100,000 people through the 100k Wellness Project, it will be possible to create expert systems for wellness that can be distributed through digital health technology to billions of people.2
My personal dream is for doctors and patients to be unburdened by chronic disease and for healthcare dollars to go toward solving rare diseases, eliminating infectious plagues, and curing cancer. This is the beginning of a new era of medicine where patients will be active participants in their healthcare; where people do not fear genetics or blame genetics for health problems; where we are empowered with data to make informed decisions that will alter the expression of their genes and course of our lives. In an illness paradigm all you see is pathology, but in a wellness paradigm all you see is potential and engaged patients.
Molly Maloof is a physician in private practice in the Bay Area.
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