The Balance Between Wearable Medical Devices and Incidentalomas in Today’s Tech-Driven World
You don’t need me to tell you that we live in the age of digital medicine. Newspapers, magazines and even professional health journals are thick with stories about how wearable devices like the Apple Watch and Fitbit will revolutionize healthcare by providing real-time monitoring.
Imagine being able to screen for the two most common causes of death in industrialized countries – heart disease and cancer – by checking your lipid profile or a panel of cancer markers whenever and as often as you want. Talk about health vigilance.
What Silicon Valley entrepreneurs and their media cheerleaders won’t tell you is the benefits of continuous digital monitoring – the promise that we might identify serious health problems early, while a cure is still possible -- are unproven.
Even worse, they ignore the problems related to over-testing. No test is 100% accurate and the more we monitor people with a very low risk of disease – e.g. everyone who can afford a wearable device – the more likely we are to get false positive and abnormal results. This is so common that there’s a word for it, incidentaloma, which describes potential medical abnormalities found while looking for something else. The more testing done, the more incidentalomas.
I had one many years ago. My wife, also a physician, noticed a lump beneath my right shoulder-blade. Most likely this was simply a lipoma – a benign “fat tumor.” But a chest X-ray picked up an abnormality which might have represented a wide-spread, metastatic, cancer. This prompted a CT scan and an MRI. Since neither was conclusive, my doctor recommended a significant surgical procedure, rather than a simple office-based removal of the “potential” tumor, which did, indeed, turn out to be a lipoma. No harm, no foul, except for the cost to my insurance company and my missing a few day of work. But I was 37 years old and healthy. What if I had been thirty years older and not so healthy?
I’m not recalling this episode to pour cold water on the concept of technology improving health. But as we move toward widespread use of instant data feeds from wearable devices, we must guard against the profoundly unscientific yet seemingly unavoidable Law of the Magic Bullet that leads us to cast every advancement as a fountain of youth discovery, while neglecting the inevitable trade-offs they bring.
For instance, while real-time monitoring is pitched as creating a “new era in healthcare,” the fact is similar experiments have already been run in some areas. Decades ago, American Heart Association panels proposed that continuous BP monitoring would make hypertension treatment more effective. Later research showed otherwise. For diabetics, frequent blood sugar monitoring (and treatment with insulin-lowering drugs) has been a happier story. But the ability to capitalize on minute-to-minute blood glucose monitoring will only occur with widespread use of implanted “artificial pancreas” devices, many of which are still in development.
Techno utopians also leave the impression that their gadgets are magic bullets all by themselves. Putting aside significant questions regarding the accuracy of at-home devices, each single reading – your pulse rate, blood pressure, glucose levels -- is highly dependent on everything else going on inside and outside your skin, from your genes to your lifestyle to your ever changing environment. . It will likely be decades before the influence of all these factors on health will be understood.
As with most new technologies in medicine, these devices will not replace but accentuate the expertise of physicians and other health care providers. First, providers will digest your health data and compare it with information now available at lightening-speed from medical research. Second, and more importantly, only an experienced clinician can evaluate these data in the context of their experience to give you their best opinion on how to proceed. Most times as a physician, there is no single answer to the question of “what should I do now?”
Finding the proper response will only become harder because all of this individual data, along with the rise of genomics and sophisticated new diagnostic tools, is already revealing subtle but significant variations in the biology and chemistry of every person, further making diagnosis and treatment decisions more complicated
Dr. Eric Topol addressed this in a recent op-ed on nutrition in the New York Times which challenged “the idea that there is one optimal diet for all people.” We now know, he wrote, that different people “do indeed respond quite differently to eating the same foods in the same amounts.”
As physicians wrestle with the intellectual challenges of processing these new mountains of information, they will also have to sharpen their soft skills to communicate more openly and effectively with patients empowered by these same new technologies. In the age of real-time monitoring, physicians are not just caregivers but also care partners.
These developments and insights are signs of real progress. But we must also acknowledge that we are entering uncharted waters. As new technologies redefine the doctor/patient relationship in terms of collecting and communicating medical information, they also suggest the need for new forms of highly personalized – and probably more expensive – forms of care.
Digital medicine is an exciting breakthrough, but it is no magic bullet. In the years ahead it promises to solve many problems, while raising new questions and complications.
You can set your Apple Watch by that.
Marschall S. Runge, MD, PhD, is Executive Vice President for Medical Affairs and Dean of the Medical School for the University of Michigan. He serves on the Board of Directors for Eli Lilly and Company.