Imagine it’s the future, especially in the field of diagnostics for the medical field. Envision your future self-rolling out of bed in the morning and moving to the toilet. You have a “smart” toilet but it is an older design, and you are considering getting a newer version.
The old version of your toilet can provide diagnostic information like a basic urinalysis, picking up signs of disease, or developing diabetes. And it can warn you to blood in your stool, an indication of colon cancer. Your particular test-strip toilet tissue gives you a green thumbs-up on 30 different daily diagnostics. And the toilet reports your gut microbiome is up to snuff.
But your model does not test for any of the several healthful new gut bacteria found among African hunter-gatherers. What really has you seeking to get a new toilet, though, is the lack of data-share options for your old toilet. Honestly, your physician and one emergency contact? That’s it?
Who is going to help you make sense of all of this info?
What about the global health record data bank (GloMM), started in 2021 that stores and shares all your mobile and other health data?
What about your two dating sites? A lot of partners want to know about your health state.
Back in the present, we heard from Sanjiv Sam Gambhir, MD, Ph.D., who is working to interpret such a situation — or one somewhat like it-into reality. Gambhir predicts a future where we nearly regularly monitor our health.
The obtained diagnostic information data might be submitted to our health-care team or us right away if something is missing. Are we developing little aggressive tumors? Is a small tremor suggestive of the onset of neurodegenerative disease?
Current diagnostics, states Gambhir, are so intermittent, it is like trying to watch a movie but watching it just every 20 to 30 minutes for a few minutes every time until near the end of the film when you get to watch it for a couple of minutes. We’ll miss critical parts of the story.
Generally speaking, diagnostic information is often underappreciated. According to some 2015 National Academy of Medicine report, “The delivery of health care has proceeded for decades using a blind spot: Diagnostic mistakes — incorrect or delayed diagnoses — persist during all settings of care and continue to impact a countless number of patients.” Gambhir is among those few who recognize how systemic the problem is, how colossal the challenge, and who wants to change things.
The underpinnings of greater stress on diagnostics will be devices that can track health at all times. Radiology teacher Seung-min Park is currently serving to set the basis for the diagnostic eyesight of Gambhir. If you continuously monitor the body, says Par, you cannot do that with anything such as X-ray imaging, operation, or blood draws. No, one would place up with that.
It’s clear, Park says, the ideal sources of diagnostic information are the molecular contents of saliva, sweat, feces, and urine, naturally excreted every day and packed with information. Researchers around the world have recognized that these substances can give clues.
Park is modeling a smart-toilet prototype that can get urine for examining multiple times a day. To start the project, he is using an off-the-shelf commercial test strip which measures 10 factors like acidity, which can tell you about your risk of kidney stones, and glucose, a sign of diabetes.
The Gambhir Laboratory is currently working on a bra made to consistently image breast tissue. The bra takes a blend of infrared light and sounds to picture and identify minuscule breast tumors, so they can be treated long before they extend. Like the smart toilet, the smart bra is under progress. For now, the laboratory engineers are thinking hard over challenges such as how to analyze the nonstop stream of information and where to place the battery.
Cardiologists are making the vision of constant monitoring a reality. Info from pacemakers and other devices implanted in the heart can be sent automatically with ultralow radio frequencies so that patients can be observed for signs of crisis.
For instance, when an infant was born with a mortal heart arrhythmia, her physicians at Lucile Packard Children’s Hospital Stanford inserted a defibrillator and pacemaker in her heart that could report back to her physicians if the defibrillator was activated. At 7 months, the defibrillator started to go off. Even though the baby looked fine to her parents, she was in serious trouble. The hospital advised the parents to bring the baby in immediately, and within weeks a heart transplant saved her life.
Gambhir’s Vision
Diagnostic information has moved far past old-fashioned X-rays for broken bones. We live in a world where, if we wanted, we could track our health around the clock with an assortment of ingenious devices that has the potential to help foretell illness.
Wearable and implantable devices can provide rivers of information that can both help health-care systems to track the well-being of individuals and assist researchers in studying the efficacy of treatments or preventative health programs in whole populations. Some folks won’t need to be monitored all of the time, Gambhir acknowledges, but he believes that for many, the hope for the benefits will overcome their concerns about privacy.
Gambhir compares diagnostic medicine’s future to the approach used to maintain the engines of business jets spinning evenly and reliably. “Many people have taken a flight on a commercial jet,” he says. “You might not know it, but the jet engines on this plane are nearly continuously monitored through an engine-health portal that sits in Rolls-Royce or General Electric. Every 30 seconds, each engine on the jet sends signals down to the engine-health portal.
Numbers of sensors mounted into that jet engine are allowing the health portal to know if there is an issue with the engine — also in flight. When there’s an issue, alterations to the engine could be made, with no pilots knowing, still in flight.” For more severe problems, a plane can be made to the land. Jet engine engineers have learned and when not to intervene, continue to track— to avoid false alarms.
“There is no true equivalent in medical care,” states Gambhir. “There is not constant monitoring of your well-being. The future is all about having the ability to catch illnesses early and limit them. If we could actually do something about a disorder like aggressive cancer, then it’s worth tracking for it.”
However, when research dollars are doled out, medical diagnostic tools are often used as an afterthought, Gambhir states. People do not think of diagnostics as saving lives. Still, therapy depends heavily on accurate medical diagnosis — and biomedical research even more so. Expenditures on the subject of diagnostics research aren’t tracked individually. Still, he estimates that no over 7% of total biomedical research dollars spend on diagnostics, while the rest is going to find always more treatments.
Gambhir would like to see that ratio reversed so that the “anticipating and preventing disease” part of Stanford’s precision health program takes preference over countless new treatments.
Although he concedes, he would be happy with a 50:50 funding split between therapeutics and diagnostics and expects such a transition in the next few years. It makes far more sense, he asserts, to put resources into preventing illness or diagnosing the disease early — when, often, it’s much easier to deal with — than doing nothing until folks are quite ill.
However, the way biomedical research is funded and how medicine is practiced is structured around treatment, not a medical diagnosis. So a diagnostics-first procedure would mean significant changes.
Redesign Treating The Patient
Kathryn McDonald, the executive director of the Center for Primary Care and Outcomes Research, and Stanford’s Center for Health Policy agrees with Gambhir who diagnostics are critically understudied, given how important they are. “Our health-care process is organized about what happens once you already know what’s wrong, as compared to finding out what’s wrong,” McDonald states.
In 2015, the National Academy of Medicine stated that at least 5% of U.S. outpatients undergo a diagnostic error, 6 to 17 percent of adverse events in hospitals result from diagnostic mistakes, and diagnostic errors contribute to 10 percent of all patient deaths.
Yet, despite the value of diagnostics, they get minimum funding, says McDonald, who works at the National Academy of Medicine’s Committee. “If you examine the dollars related to diagnostic testing, it just pales in comparison to dollars spent on pharmaceuticals. And there is a parallel in the research world.”
One reason is that diagnostics is mainly a cognitive exercise, McDonald states. It’s your doctor sitting and studying, reading, calling a colleague, thinking some more, and talking until they find out what’s wrong with you. And there is almost no support for speaking and thinking, she says. Doctors and others are rewarded for treating patients and, to a lesser extent, for observing patients, but not for thinking about them.
We have to look for ways to reward that cognitive work and teamwork, says McDonald.
False Negatives, False Positives, Creates False Reassurance
Although the diagnosis may happen through communication and thinking tests, diagnostic information tests themselves, and how physicians think about them, are susceptible to error. Tests are notorious for generating false negatives and false positives, and the rarer the condition, the easier it is to be duped by inaccurate information.
In the case of a test for blood in the urine, a false positive could indicate there was blood when there was blood there. Similarly, a false negative would necessarily be a miss; the test result would say there is no blood when, in fact, there is.
False positives can generate plenty of anxiety and waste health-care dollars for everyone. But besides the issue of false negatives and positives, McDonald points out that monitoring could be more inclined to false reassurance. If you’re using a bathroom or smart bra, she says, you may decide you do not require a regular lab test. However, the device could stop working, and you might not know it.
Combine Pieces Of The Puzzle
Diagnostic information could be data from wearable devices, says a part of the cadre of investigators interested in what diagnoses can contribute to medicine’s future, Saxon. “However, diagnostics can also be what patients are telling the doctor, or what their mom or sister are telling them.
For instance, Information from the device for monitoring heart activity needs to be considered in the context of what else a doctor knows — whether a patient is taking their prescriptions or how the doctor is using the monitor.
And biomarkers and diagnostics are a piece of the puzzle. The challenge may be handling that information — processing it, incorporating it, and sharing it in a way that helps both researchers and patients.
Don’t Jump Too Fast
Peter Schmidt, Ph.D., chief mission officer and senior vice president at the National Parkinson Foundation, sets a gimlet eye on what he observes as over-enthusiasm for diagnostics and biomarkers.
It is not against diagnosing people who are ill. But not all diseases are targets for monitoring, ” he says. Cancer, for instance, is an appropriate goal for tracking as it easy to deal with when caught early, hard, or impossible to deal with when finding later. But neurodegenerative diseases like Parkinson’s disease are difficult to treat in any way, let alone heal, so knowing before you feel ill, you’ve got it could be a drawback.
“A human is not an engine, and we deal with issues in our own way,” Schmidt says. He questions the wisdom and integrity of diagnosing people with diseases when they feel fine and when intrusion won’t clearly do them any good.
Imagine that you are 70 years old and feeling fine, but a test has just revealed that you have Parkinson’s disease. “You are not really aware of any symptoms, then you die a couple of years later from a heart attack. Knowing you have Parkinson’s disease will not help you in any way.
“Parkinson’s Disease can be effectively controlled for a year or two after analysis,” Schmidt adds. “For that two-year interval, Parkinson’s disease is mostly a disease of fear, where people will think, ‘finally, this disorder will conquer the effects of the medications, and it is already doing something bad to my brain.’
Current Obstacles
Diagnostic information comprises far more than simply figuring out what’s wrong with one patient. If the medicine is approaching a more precautionary model, that will need better diagnostics. A future demands support for research on structural and diagnosis support for accurate and timely identification, says McDonald.
“And,” she says, “The study isn’t only about training doctors to do a better job. It is about how the delivery process is supporting them so, the way the payment process is supporting them in doing so, the way the legal system is supporting them in doing this.”
The number of people looking at the way the whole health-care system can encourage using diagnostic information is, for now, a “small tribe” of individuals, says McDonald. “This difficulty matters. It requires attention, and no one is funding the study to build a knowledge base that will assist you in writing your article,” she says with a grin.
As Gambhir emphasizes, the changes could take decades, and the challenges are manifold. At one level, the problem is in knowing our biology and the output well enough to know what to do with this info. The biology of early disease isn’t necessarily the same as that of late illness. Another significant challenge, says Saxon, is currently processing and handling and sharing that information in a way that helps patients. And, since McDonald says, “The present health-care system is shaped more for treatment than for identification, more for action than for thinking.”
The smart bathroom of the future will not be an independent device, but part of an integrated network of data about you and billions of other people, in a system of servers, devices, institutions, and people— that actively prioritizes communication, diagnosis, and prevention. Rather than flushing millions of petabytes of data into the trenches each day, we’ll obtain from it the roots of a healthier future.
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