Peas, flies, and your practice
I'd like to ask those of you in primary care to use your imagination and go to a place you may never have thought you'd find yourself. Like replacing surgeons. Like truly being the go-to guys for the most advanced treatments.
Picture this: Your patient, a 49-year-old man, comes in complaining of occasional shortness of breath and chest pain on exertion. You're not surprised. He smokes; he's overweight; medication has kept his cholesterol levels in check, but just barely. His father died of an MI at age 52.
Stress testing and angiography indicate blockage of the coronary arteries, but not to a level that angioplasty or CABG is indicated. You begin treatment in your office with IM injections of genetically engineered coronary artery growth factor. The patient will get one injection every month, and within six months blood supply should be fully restored. You'll also start him on therapy that will keep the arteriesold and newclear. Chances are, he'll never need cardiac surgerynor will any of your other patients.
The odds of that scenario happening are getting better all the time, thanks to the work on the Human Genome Project and the genetic therapies that have sprung from it.
Angiogenesis is in phase II and III clinical trials. Gene therapy to reverse heart failure is being tested, too. In fact, genetic therapies are being explored in virtually every realm of medicine. Enough so that speakers at last month's American College of Obstetricians and Gynecologists urged attendees to start brushing up on their genetics immediately. Enough so that some people are predicting that we won't need surgeons anymoregenetic therapy will be so refined that the diseases we can't prevent will be curable noninvasively.
Exciting as the scientific possibilities are, you've got to start preparing for a new mode of practice.
New-patient visits will still begin with a history and physical, but there's every likelihood that that history will have to include detailed genetic information. (Talk is that everyone will have his genetic code imprinted on a chip that he'll carry around.)
The standard of care will be much more focused on prevention, and that prevention will require action on the physician's part. Counseling a patient about what he has to dolose weight, stop smoking, and exercisejust won't cut it.
You're also likely to be referring far fewer patients to specialists and admitting fewer to hospitals. First, you'll be preventing most of the illnesses that send them to specialists now. And you'll have the treatment modalities available to administer yourself, on an outpatient basis.
Patient education will become more complex, too. Not only will you have to explain the intricacies of genetics and why this or that treatment will work, you'll need to explore the ethical and legal ramifications of testing and treatment, as well.
Will you be able to handle all that patientsand the countrywill expect a primary care practitioner to do? Probably not without rethinking how your office is staffed and what each person, including yourself, is expected to do.
Is all of this too far down the road to worry about? By the end of this decade, experts expect there to be reliable genetic tests that will accurately predict a patient's risk for at least a dozen common conditions. Tests for breast and colon cancer already exist. Gene-based "designer drugs" tailored for an individual's genetic makeup are expected to be on the market by 2020. And there'll be gradual changes you'll have to keep up with between now and then.
So, no, it's not too early to start thinking about the implications of genetic marvels on your everyday working life. Nor is it too early to plan for them. At the very least, dust off the genetics textbook and get reacquainted with Gregor Mendel's peas and Thomas Hunt Morgan's fruit flies. Then you can move on up the ladder through Watson and Crick and into tomorrow.
Marianne Mattera. Memo From the Editor: Peas, flies, and your practice. Medical Economics 2001;12:4.