The Concept of Medicine 3.0
I thought it would only be appropriate to discuss a concept from Dr. Peter Attia’s new book “Outlive: The Science & Art of Longevity” with my first blog post here, as I have been an avid reader of his blog for the last decade and it has been a big inspiration in how I practice medicine today.
While there are many fascinating topics in the book, many of which I hope to discuss here at a later time, one of the most important is the concept of Medicine 3.0. Medicine 3.0 is a change in how medicine is practiced, changes that I hope to incorporate with all my patients at Arthritis & Wellness Institute.
What is Medicine 3.0, and why does it matter?
To understand Medicine 3.0, it is important to first look at the previous two versions of medicine. Dr. Attia dates Medicine 1.0 as far back to the time of Hippocrates. It was medicine based purely on observation and guesswork. While some of their conclusions still hold true today (Hippocrates famously opined “in food excellent medicine can be found; in food bad medicine can be found.”), others were off the mark (the 4 bodily humors for example). Medicine 1.0 lasted until Medicine 2.0 arrived in the mid-nineteenth century with the advent of germ theory of disease. Medicine 2.0 was transformational- it utilized new technologies and more importantly a new way of thinking, what we now know as the scientific method. Medicine 2.0 brought us antibiotics and vaccines and eradicated or treated many diseases thought to be deadly- including smallpox, polio and hepatitis.
Dr. Peter Attia
As successful as Medicine 2.0 has been against these type of diseases- it has been far less effective against chronic or long-term disease such as cancer or heart disease. It has become clear our current training and way of thinking in medicine is geared to the acute problems that faced medicine decades ago. But with the rise of chronic diseases and mortality rates remaining unchaged a shift is needed. This is where Dr. Attia’s concept of Medicine 3.0 comes in.
The basis of Medicine 3.0 can be described in 4 main points:
Medicine 3.0 places a far greater emphasis on prevention than treatment
Medicine 3.0 considers the patient as a unique individual
Whereas in medicine 2.0 everyone was treated the same, and assumed the findings of a study applied to everyone the same. In medicine 3.0 it uses the findings of evidence based medicine and goes one step further, looking closer at the data to determine how each patient is similar or different from the "average" study participant to better apply the study findings
Medicine 3.0 starts with an honest assessment, and acceptance of risk- including the risk of doing nothing
At each individual patient we should be willing to ask deeper questions of risk versus reward versus cost for therapy.
An extremely important example of this is HRT in women. Following the WHI study in 2002 (a study that was both limited and flawed) the use of HRT in women dropped drastically. The headlines from the study reported a 24% increase in breast cancer in women using synthetic estrogen. As scary as that headline sounds- the absolute risk increase remained minuscule. For every 1000 women in the HRT group, 5 women developed breast cancer. Meanwhile for every 1000 women in the placebo group, 4 women developed breast cancer. This tiny increase in absolute risk has prevented millions of women from using a medication that not only very effectively treats symptoms but has also been shown to reduce the risk of bone density risk, cardiovascular disease and even Alzheimer’s disease! (I could discuss the WHI study and the harm it caused in much greater detail- and plan to have another blog soon doing exactly that)
Medicine 3.0 pays far more attention to maintaining healthspan- the quality of life. Where as Medicine 2.0 focuses largely on longevity.
An analogy Dr. Attia describes for Medicine 3.0 vs. Medicine 2.0 is the iceberg analogy. Medicine 2.0 only deals with issues once the iceberg is visible above water, and likely too late to avoid as it was for the Titanic. In Medicine 3.0 we are deploying the tools to detect these icebergs far in advance, and implementing strategies to help our patients steer clear from impending crises.
Dr. Semmelweis and the dangers of perseverance beliefs
Dr. Ignaz Semmelweis
The transition from Medicine 1.0 to Medicine 2.0 was not a smooth transition- as exemplified with the story of Dr. Ignaz Semmelweis. Dr. Semmelweis was a junior obstetrician (or equivalent of a Resident physician today) in Vienna in the 1840’s- and became concerned with increasing cases of “childbed fever” in one of the maternity wards- this ward in fact had a maternal mortality rate nearly 5x higher than the other maternity ward on the same campus. After ruling out all the possible differences between the two maternal wards- Dr. Semmelweis concluded that the only difference was the staff of each ward. The ward with the high mortality rate was mostly staffed by medical students and teaching faculty, many of whom were also performing autopsies. This led to Semmelweis hypothesizing a "cadaverous particles" on their hand was being transferred from the staff to the patients and responsible for the perpetual fevers seen in the maternal ward. He then instituted a new policy requiring hand washing with a chlorinated solution before examining patients- this one change led to a decrease in mortality rate from 18% to 2% within two months. Germ theory had not been discovered by this time and Semmelweis findings did not sit well with many of his colleagues and higher ranking physicians who continued to hold on to outdated believes, and became upset with the implication something they had done was responsible for the large number of maternal deaths. This resistance and insistence on sticking with dogma (a form of perseverance belief) would lead to Semmelweis being ostracized from medicine and eventually to his death in an insane asylum in 1865. Unfortunately Semmelweis’ contribution was only recognized 20 years after his death as the medical world became more receptive after germ theory of disease by Louis Pasteur and concept of antisepsis was proven by Joseph Lister.
Similarly I do not expect the transition to the ideals of Medicine 3.0 to be quickly accepted. While perseverance beliefs remains an issue as it did in the 1800’s, this time the battle is also with billion dollar insurance companies, who have no motivation to change when their only metric of concern is the bottom line and dollars saved. Traditional insurance based doctors are not rewarded, nor have the time necessary to teach a patient to change the way she eats and exercises or monitor her blood glucose levels to prevent type 2 diabetes- but insurance companies will pay for the very expensive insulin once that same patient develops diabetes.
