Why Behavior Change Is (Still) Better Medicine Than Drugs

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While attending the Institute for the Future's Health Horizons Fall Conference on Monday, one thing became eminently clear. The 21st century will be the era of brain, the last great scientific frontier. Due to societal shifts, environmental changes, and the fact that we are just living longer, we are poised to see a sharp rise in cases of diseases such as Alzheimer's, Parkinson's, autism, and post-traumatic stress disorder. The only thing worse than the increasing prevalence of brain disease is the sobering fact that few viable treatments currently exist.

For years, we've heard the mantra of behavior change and health. Exercise more and you'll cut your risk for heart disease and stroke. Eat more fruits and vegetables and you can decrease your risk for colon cancer (or possibly prostate cancer, as discussed in a previous Decision Tree post, "Why Behavior Change is Better Medicine than Drugs"). Could behavior change serve our brain health as well as it did other organs of the body?

On Monday, the neurotechnology community drew a definitive line in the sand with regard to treating the brain.  On one side were panelists that believed that society is not being medicated enough for mental disorders, including ADHD in children. On the other side, proponents of behavioral training argued that brain plasticity, the innate ability of the brain to rewire itself continuously throughout life, is our best bet to combat brain disease.

Consider the use of ADHD drugs in children, or cognitive-enhancing drugs, such as modafinil, by professionals (including a large group of scientists) in the workplace. Proponents of medication say that the cognitive enhancers are not doing anything unnatural. Rather, they are taking someone who's a mediocre performer in terms of concentration, and simply moving them to the upper 90th percentile. Then, according to the same logic, I guess these panelists would also support legalizing steroids in major league baseball. After all, the steroids are not making the athletes super-human. Rather, they're taking the middle-of-the-road performers and nudging them to the upper echelon of the sport. Hmmm....

My former postdoc advisor, Dr. Michael Merzenich of the University of California San Francisco, led the charge for behavioral training as a better alternative to drugs for diseases of the brain. Mike's lifelong work focused on the neuroscience of learning, and how brain plasticity occurs at various stages of development. He believes that many ailments of the brain, including ADHD, occur because we are using our brains "incorrectly", but specific behavioral training can reverse and improve these deficits.

The wonders of behavioral training and brain plasticity are not limited to sparse findings in a dark lab. In fact, Mike's most promising research has been translated into several commercial computer software applications, which have enhanced the reading capabilities of dyslexic children, as well as improved the speech processing and memory of senior citizens.

Whether you are sold on behavioral training as a feasible alternative to drug therapy in brain illness or not, one point remains solid: the cost of conducting clinical trials for behavioral training regiments is a mere fraction of the cost of drug trials. Given that it's terribly expensive to run drug trials, and that only a small fraction of drugs in a pharma company's pipeline succeeds in the clinic, we clearly can't afford to ignore behavioral training as a new way to treat the brain.

Will Keas Live Up To Its Potential?

"The human body does enormously well healing itself," Keas founder, and ex-Google Health lead, Adam Bosworth told Health 2.0 conference-goers shortly after stepping on stage.  On the heels of an article in the New York Times that touted the company's beta launch, Bosworth walked the crowd through the way we'll keep ourselves healthy in the future, using Keas' platform.

Over the past few years, Bosworth carefully watched as the Health 2.0 revolution unfolded. Medical issues became less of a private experience.  People, who at one time only discussed personal ailments with their family physician, now turned to family and trusted friends for medical advice.  With the boom of the Internet, a person's trusted medical community suddenly became infinite.

Of all people, Bosworth understood the potential power of the internet on health, where the collective wisdom of the patient population could reach thousands, or millions, of other people.  So he wondered, if people were readily turning to the web for information when they got sick, could customized, preemptive web advice keep people from getting sick in the first place?

Keas' system uses custom "Care Plans" that collect personal data that the user either uploads at the website, or is transferred directly from a lab, like Quest Diagnotics.  Keas plans to run its own iPhone-like App Store, where doctors or other health care providers create their own Care Plans, integrate them into the Keas platform, and instantly distribute them to millions of people.

By personalizing the measures we can take to stave off certain predisposed conditions, Keas' Care Plans should improve our health.  But the real promise of the company, wasn't in what Bosworth delivered onstage, but rather, in something he simply mentioned in passing.  Bosworth alluded to the idea that not only will Keas' platform let people track their own health, but it could also allow people to keep tabs on their family's health as well.

Imagine logging into your Keas profile, and being presented with a dashboard that shows the current health information for your spouse, child, and elderly parent.  Did your husband get his blood work test today?  How much has your child exercised?  Has your 80-year-old father read the online information packet on "Preventing Falls in the Home"?  At a glance, you'd have this information in front of you on the Keas website, if the company follows through with this idea.

When people become chronically ill, or simply start living into their eighties and nineties, maintaining health shifts from an individual to a team sport.  There's too much information for one person to process and comprehend.  Too many medications.  Too many things to keep straight.  Current estimates put 30 million people in the US as primary caregivers -- adults, aged 18 or over, who maintain the personal well-being of another adult.  Keas' program has the potential to make the term "long-distance caregiver' obsolete.  Everyone would be just a click away from checking-in with their loved ones.

Join My Photostream, Doc

The most impressive tool for clinical decision-making presented at the Health 2.0 conference was a program that allowed docs to share medical images over the Internet, developed by MyPACS.net.  Any DICOM image (e.g. CT scan, MRI, etc) can be uploaded and shared through their website. Say, for example, that a patient comes to the hospital with abdominal pains.  After undergoing a CT scan, the radiologist determines that there is a mass located in the abdominal cavity, but is not quite sure what it is.  Traditionally, the radiologist would either compare the patient’s CT to scans in the hospital archive, or spend hours searching through the limited information in medical journals.  With MyPACS.net, doctors can upload and share hundreds or thousands of images, instantaneously.  It’s like Facebook photos or Flickr for physicians.

Not only would this system help a small-town hospital that has limited DICOM image archives, but it also eliminates the 6-10 month lag in publication of images in medical journals.

Behavior Change: A Central Topic at Health 2.0

The afternoon of Day 1 of the Health 2.0 Conference was highlighted by the session, "The Patient is In".  First up, a video that documented the experiences of a group of people that recently started using patient health tools, such as online health journals that track diet or exercise, support sites for quitting smoking, or home blood test kits.

Following the video, a few of the participants were joined onstage by technology pioneer Esther Dyson.  Some panelists said that while they exercised a bit more and ate somewhat better during the course of the experiment, soon after they returned to their old (bad) habits.  Others were completely sold on the idea of self-tracking, and one particular panelist said that his daily running and mile-logging inspired his daughter and her friend to do the same.  Likewise, his neighbor, having noticed him trotting around the neighborhood several times a week, started his own walking regiment.  In the panelist's words, "People draw energy from supportive environments".

Social contagion, the idea that behavior change can be contagious, has been gaining ground.  A few months ago, I experienced the power of social contagion for myself: as many readers know, I'm a long-time runner.  But no matter how many miles I logged per week, my wife never really understood why I was out on the road, tormenting myself for hours.  It wasn't until she bought a Nike+ sensor, and her boss challenged her to a "See Who Can Run More Miles in a Month" challenge that she became hooked on running.  Now I have to spy on her website running log to make sure I still run more miles per week (yes, I'm competitive too).

Some people are inspired to change their behaviors by logging how many calories they're consuming every day.  Others are motivated by seeing friends or family stop smoking.  And for some, it takes someone else to throw down the gauntlet, and say, "I bet I can kick your butt in a race around the track" for the change to occur.

Esther Dyson concluded the session by saying that we can also drive behavior changes by associating the things we just don't like to do with small "rewards".  Personally, she rewarded the monotony of flossing with a 5-minute reprieve from her intense exercise routine.  So on days she flossed, instead of swimming for an hour, she could quit after 55 minutes.

Social contagion and little rewards go a long way in keeping people focused and motivated, and I was glad to see these ideas brought up at today's conference.

Health 2.0 Conference: Clinician-Patient Interaction

The morning session focused on clinician-patient interactions.  Executives from Myca, VisionTree, AmericanWell, and ReachMyDoctor, presented their virtual doctors' office visit tools. All of the tools had similar features, such as online scheduling, and the choice of different types of offices visits, such as IM chat or video.  Most integrated well with personal health records, so that during an office visit, the physician had access to the patient's medication refill history, or overdue routine preventive medical tests, such as blood-work, prostate screens, or mammograms.

At the end of the panel discussion, several good questions were asked.  People wondered what incentives were in place for physicians and patients to use the system, especially if each doctor was using a different system.  Does this mean that the patient will have to log on to two different websites if their general practitioner uses HelloHealth, but their cardiologist uses AmericanWell?  The panel responded that each of these web applications was part of a larger central platform.  It may be more helpful to think of each web tool as an individual iPhone app.  iPhone apps can communicate with each other and run on a single system (phone), so it's possible for these individual web tools to play nicely together in the future.  One question I had: where are all of the patient tools that plug into this central platform?  Maybe that's tomorrow's talk...

The second session brought out some pretty tough critics of the virtual doctor's office idea.  Although these new panelists liked what they were seeing and hearing, at heart, they were still physicians that saw many challenges to using these products in their own practice.  A psychiatrist was the first to challenge, saying that good psychotherapy demands face-to-face interactions.  I've seen this type of push-back from doctors before while consulting at medical device start-up companies.  No matter how transformative or revolutionary the new technology could be, unless doctors can easily integrate the technology into their current practice, the idea may flounder.

Yesterday at the Kaiser HealthCamp Un-Conference, a cool term surfaced -- "minimally disruptive technology" -- which was used to describe an approach to reform health care technology that pushed progress, while not upsetting the status quo, so to speak.  Granted, there is a learning curve associated with any new technology, and to implement an idea such as virtual doctors' office visits will require significant infrastructure changes in the medical community.

Will only a fringe group of early adapters use this technology?  Is it realistic to think that a majority of doctors will use such a system?  Too early to tell, but it wouldn't hurt to get some of the nay-sayers involved with the design while the concept is still in its early stages.

Health 2.0 Conference: Keynote Address

The Health 2.0 conference kicked off this morning, amidst the booming call-to-action by the U.S. Chief Technology Officer, Aneesh Chopra during the Keynote Address.

Chopra assured the crowd that he was "deeply committed to the role entrepreneurs play (in the future of health care)".  Yet, he wondered whether companies were using all of the resources currently available to them, when he asked "How many companies are using Small Business Innovation Research grants (SBIR) to bring their products to market?".

According to Chopra, the U.S. government has new initiatives on the horizon, such as subsidizing 2/3 of the salaries of 40 postdocs who decide to enter industry.  That means an employer can pick up a new PhD hire at 1/3 of the cost!

Chopra concluded by addressing the current economic downturn with his "light-at-the-end-of-the-tunnel" attitude by saying "the next round of Fortune 500 companies will be born in this era".

My take: it was a good introduction to the potential promise scattered throughout the room.

Kaiser Permanente Health Camp: My First "Un-Conference"

As a prelude to the Health 2.0 conference in San Francisco, I went to Kaiser Permanente's HealthCamp today, located at their amazing Garfield Innovation Center.  Being a scientist, I've attended my fair share of conferences over the past years, but none prepared me for what I experienced today at my first "un-conference". First, for those who don't know, an un-conference has no set agenda; the sessions are made up by the attendees the morning of the conference.  This way, the topics covered throughout the day truly reflect the attendees' interests.

First up, were three introductory talks by leaders in the Health 2.0 community.  Dr. Robert Pearl, from Kaiser Permanente set the tone for the day when he described a sign he noticed over a decade ago at Oregon Health & Science University that read "Quality, Service, Cost".  Dr. Pearl said that the 20th century mentality for health care could only focus on 2 of the 3 at any given time.  But now, in the 21st century, we need to address all three simultaneously.  Dr. Pearl challenged the notion that doctors are old-school, or that they are unwilling to learn new technologies, claiming that they are constantly looking for innovation.

A common theme in the opening talks was best summarized by Dr. Kaveh Safavi of Cisco, who said we need to distinguish between "personal care" and "in-person care".  Dr. Pearl agreed, and believes we are on the cusp on integrating tele-medicine in the emergency room, so that patients will have more, and faster, access to specialists, which will streamline medical care.  Patricia Perry, of Intel, concluded the opening remarks with her insight into "Aging at Home", where in-home patient medical monitoring and video-based doctors' visits can actually improve medical care for senior citizens.

I spent the rest of the day floating around to different sessions, trying to absorb as much information as humanly possible.  I heard some really interesting concepts being discussed, such as creating a "LifeScape", which is the intersection of our different worlds: such as work, health, and communication.  People thought that to be truly innovative, we had to find ways to create "stealth health", where healthy decisions are simply a consequence of another easier choice.  One design example was a school's lunch line: research shows that if apples are placed before the sweets in the line, kids are more likely to make the healthier choice.

In another session, I learned about a cool new social media site called Aardvark, which answers users' questions by connecting them with "experts" in the field.  So opposed to crowd-sourcing your question to your friends on twitter, now your questions gets directed to the people who may best answer it.

Self-tracking was a popular topic, and I see more and more people unleashing the power of personal data.  I heard the battle-cry for more effortless sensors, where data is collected without any extra work by the user.  But I found out that many people still aren't interested in the nitty-gritty details of the data.  Rather, they wanted all personal metric information to boil down to one measurable "health score" -- a single number that defined their health.

All in all, a solid day of innovation, great conversations, and a heck of a way to kick off Health 2.0 week.  Lastly, the organizers did a fantastic job with the event.  The un-conference format is great way to initiate dialogue and get involved.  I'll definitely be back to HealthCamp next year.

Stay tuned the rest of the week for my updates from the Health 2.0 conference!