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DR. STRAUS: This is absolutely an invigorating vision, and I will say,
if I could distill this, how is this presentation different than any other presentation?
I think you're restoring two themes to medicine that we've lost. We love the science.
In fact, it's my colleague I shared a lab with for 15 years who wrote that editorial.
DR. SNYDERMAN: I figured you had something to do with it.
DR. STRAUS: I encouraged him to do so, because he was worried about
getting into anything about complementary and alternative medicine.
DR. SNYDERMAN: Right.
DR. STRAUS: And that is, you're restoring, not only compassion, but humility in medicine.
And we've lost our humility. And it's so important that patients themselves understand, it's what makes the difference,
when we acknowledge what we know we don't know, and our willingness to partner with them, to do the best we can together.
So this is really powerful. And so this is an impressive vision.
How do you build this system? Is there a test bed or model for this? And how do you implement this vision?
DR. SNYDERMAN: Well, this is, as you know, this is not easy.
And I think anybody who thinks that there will be a major,
almost instantaneous transformation of how health care is delivered in the United States,
all they need to do is ask Hillary Clinton, and I think she'll tell you: it's not going to happen.
But as a scientist, I am sure that you will support the idea that we need to develop meaningful pilots.
And what we have been trying to espouse is that we ought to develop meaningful pilot tests of prospective care.
And in the pilot tests, the components of that test -- and a lot of what we are doing is still theoretical, still very elementary
is to take a population of individuals that have insurance where the insurer
the person who is paying the bills as well as the people
are willing to risk the fact that if they support programs like this, at least over a period of years,
the expenses will not go up and will likely go down.
If you have people more involved in early intervention.
The elements that are necessary is for each individual to have a health risk assessment.
So you need to have a tool to evaluate that person's risk, whether they are high risk, low risk, or already have early or established disease.
If they have established disease I am firmly committed to enlightened what we call disease management.
I think if it is done effectively, what it really does is make sure that individuals have appropriate standards of care,
and support very often with what we would call a health care coach.
But by getting people involved -- and, as you know, we started this at Duke.
Since at Duke we are self-insured, we have about 35,000 people that we care for at the Duke health system,
on a voluntary basis, we have allowed everybody who has their insurance with Duke
which is, as I said, about 35,000 people -- to have a health risk assessment.
They set their own health care goals. So based on their risks -- whether it's cardiovascular, diabetes, whatever
they are given a series of goals and they establish their own goals.
We have gotten all the physicians to buy into it, all the primary care physicians,
and we've done it with, hopefully, enlightened education and money.
All the patients who join are given initially, just for joining, a $25 certificate to any grocery store they want,
and if they complete a year, they get a $250 rebate.
Physicians that have patients involved in this process get an increase in their funding
to the point where a physician could make roughly an additional $5,000 a year.
We wanted to establish this, even though it's preliminary,
we don't have anything near the kind of modality that we want,
to get a working model and determine where are the problems that need to be fixed.
On a national basis, I'm spending a lot of my time trying to get leaders
in government and leaders in industry to buy into this so we develop a national movement.
DR. STRAUS: Questions? To the microphone.
Question: Would you comment on the NIH Roadmap and integrative medicine.
DR. SNYDERMAN: I think the NIH Roadmap is very important, and I've spoken to Elias Zerhouni
it gets to an issue in which I think that those of us in science, not the people necessarily at the bench,
but the administrators of science, the administrators and the individuals who determine budget, et cetera
ought to be asking at least some portion of science to look directly from the needs of the clinical arena,
let's say the clinical marketplace, to say, where are areas in which there are major problems.
Just focus specifically on a patient with breast cancer, or a person with macular degeneration, or you just name it.
And say, starting with the clinical condition on the one hand, and on the other side, the NIH and all NIH-funded
research and all the different disease areas, how do we, rather than focus solely on the push in the research and
technology to get more and more discoveries, let's say which of those things
could be pulled directly into the clinic to begin solving problems?
So I think it fits very well as a partner with what I'm talking about.
I think that the NIH Roadmap could allow the clinicians to develop far
better models to understand risks, risk, and earliest molecular detection, and early intervention.
I spent last weekend at a high powered physicians-scientists meeting and heard dozens and dozens of discoveries,
all of which, rather than just the discovery themselves, gave us insight of the process,
the pathogenic process of disease, that could allow us, if we measured these things in people,
to determine much earlier than anything we're doing right now, when a disease is beginning.
So I think it fits in as a major support system to this concept of giving people more power to impact their own health.
I am totally bought into the Roadmap.
Question: You were talking about early detection on the molecular level.
Do you think there is a role of the self-fulfilling prophecy that could come in as a danger in that? Because I know cases
if you think that you have a certain disease that you could get it. Do you think that has any kind of part in that?
DR. SNYDERMAN: Well, I think the -- don't know. But I do believe that we certainly -- based on our own attitude,
if one has an attitude that something bad is going to happen, very often it does.
Whether one could will a specific pathogenic process and make it worse, I think that indirectly that may be possible.
If we do believe that there is a lot of neurological control over many, many processes,
some of which may be immuno-surveillance, I think that's possible.
I think there are dangers.
There's no question that there are tremendous risks, and probably barriers, to give individuals information about things,
particularly things over which nothing can be done.
We have very good tests now to predict susceptibility to Alzheimer's disease.
We have chosen not to do that, not to give this to people, because, number one the predictions are just predictions.
You can't know for certain. But the other thing is, you can't do anything about it.
So I think that no matter what we think about here in terms of what would be good for science and medicine,
they really do need to be evaluated in terms of ethics, law and policy. So I wouldn't want to give you a glib answer.
I would argue that those things in which an individual could really seize and do something about in a positive way,
and provide support to help them would be a good thing.
But I could not argue and say that with some individuals, it wouldn't be good.
Question: I wonder if you have some thoughts about looking
how we might look at other, more ancient, health care systems, or systems of healing.
We tend to look at, you know, Ayerveda and traditional Chinese medicine very much in a drug-oriented way, using herbs for diseases.
And there are a lot of concepts that mirror what you talked about here.
But it's often difficult to look at them outside the context of the cultures in which they grew up,
and I'm just curious if you have some thoughts about that realm.
DR. SNYDERMAN: Well, the thought that I have is that it's a very important question.
I alluded to it very briefly in my talk, and am spending considerable time with Steve and Linda
and other people thinking about the direction of NCCAM. This is a core problem.
And that is, how do you take a basically reductionist approach to processes which are highly aggregated?
And there may be multiple slight variations of them.
Are there going to be things that people would call natural medicine, traditional medicine, that are not testable
through ways that we could currently test it, double blind, control, crossover, et cetera, et cetera?
I think -- my recommendation would be to say that we need to be very open to other ways of evaluation,
and it may very well be that we need to have a much better understanding of gathering of data without
interfering with the process itself. It's almost like the uncertainty principle.
But we need to -- it may be that we need to stand a little bit further back and just look at the aggregate epidemiological data
and see really what's happened. And is there something that seems to be different here.
Then, teasing it apart may be very, very hard, and I don't have any good insight other than if I were teasing it apart,
I would try to find within that process what seems to be the most dominant factor that may impact an outcome.
But I think initially, I would feel a lot better if I understood that the outcomes could really be measured.
Even in the complexity of the practice, depending on how you want to measure it, are people benefiting from it compared to not?
I don't know if that makes sense to you, but (inaudible).
DR. STRAUS: With respect for the time and the season. We've asked our four questions.
DR. SNYDERMAN: Yes. At least. That's exactly right.
DR. STRAUS: And it's time to thank Ralph for sharing with us this new vision, and basically admonishing
us to return to our roots, and remember what we're supposed to be as physicians, and to help us get there.
DR. SNYDERMAN: Absolutely.
DR. STRAUS: Thank you very much.