Duke leaders propose overhaul of health care and the practice of medicine

November 06, 2003

DURHAM, N.C. -- The U.S. health-care system is inefficient, wasteful, expensive, frequently inaccessible and in need of repair. So say leaders of Duke University Medical Center, who in a new article propose a plan for fixing the ailing health-care delivery system by applying the latest scientific tools, know-how and common sense. Their proposal calls for a major redirection of health care from treating disease to effectively preventing or minimizing it.

The revised health-care system should be built on a prospective approach to medicine that emphasizes personal health planning, say co-authors Ralph Snyderman, M.D., president and CEO of the Duke University Health System, and R. Sanders Williams, M.D., dean of the Duke University School of Medicine. Writing in the November 2003 issue of the journal Academic Medicine, they call for the latest medical and genomic technology to be used more strategically to overhaul the U.S. health-care system.

"Emerging scientific fields -- including genomics, proteomics, metabolomics and diagnostic imaging -- can facilitate assessment of each individual's risk for developing disease, as well as early diagnosis and effective prevention and treatment. This is particularly important for the major chronic diseases, such as cancer, cardiovascular disease, diabetes, asthma and musculoskeletal disorders, which account for the greatest burden of human suffering," Snyderman said. "Yet despite vast expenditures for health care, 40 million Americans today lack ready access to health services and effective therapies are inconsistently and ineffectively applied."

Snyderman and Williams call instead for a "prospective health care" model in which physicians would use rapidly evolving tools to determine an individual's specific risk for developing particular diseases. That information would then allow for personal health planning and interventions that would prevent or detect disease in its earliest stages, when treatments generally can provide the maximum benefit. Absent such a shift in medical practice, they argue, skyrocketing costs can provide only "marginal benefits" in an inefficient way.

Key elements of their personal health plan include a baseline profile of each patient's current health status and a health risk analysis that incorporates information about the individual's genetic background, current health, environment and lifestyle. Based on that information, physicians would provide patients with individual health plans incorporating long- and short-term countermeasures to prevent or better control disease. This would be akin to each person having his or her own health "road map" to navigate the most appropriate path to maintain a healthy life.

Successful implementation of their plan will require the further development of systems that integrate multiple streams of information about a patient and thereby make possible the personalized risk profiles and custom set of recommendations that can reduce risk, the authors write. "Health care coaches" would then assist patients in successfully implementing the plan into their daily routine.

Duke has already begun its efforts to effect the changes outlined in the article, say Snyderman and Williams. In May, Duke University Medical Center and the Center for the Advancement of Genomics (TCAG) announced a formal collaboration to create the first fully integrated, comprehensive practice of genomic-based prospective medicine. The joint venture will capitalize on TCAG's state-of-the-art genomic sequencing and informatics research facility and Duke's strong medical practice. Duke's Institute for Genome Sciences and Policy, launched in 2000 in response to the broad challenges of the Genomic Revolution, will be instrumental in addressing both the scientific and ethical questions raised by the shift in medical practice, Williams said.

A clinical trial designed to test the efficacy of strategic health planning for adults over the age of 45 with risk factors for chronic diseases such as diabetes, hypertension or cigarette smoking is now under way at Duke.
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Duke University Medical Center

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