Biohacker, MD

Wearables, executive physicals, and whole-body MRIs

Presented by Commons Clinic

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I've never loved the idea of calling patients "consumers." To me, it cheapens the doctor-patient relationship and turns health care into something more transactional than relational. Some might argue that's a good thing. In fact, frustration with the traditional health care system's inefficiencies and inaccessibility has led to the rise of consumer health care.

Health care consumerism has many definitions. One version of consumerism involves patients becoming more informed shoppers, armed with the data to make better choices about how to spend their health care dollars. Many navigation services and online tools exist to surface high-quality, cost-effective care. Consumerism also means improving the patient's experience within the traditional system. Concierge-level care, patient engagement tools, and white-glove service are now differentiators.

Another flavor of consumerism, and the topic of this post, is health care-tangential services — end-user focused solutions that exist on the fringes of the medical establishment. Specifically, we'll discuss wearable devices, executive physicals, and whole-body MRI scans. Are these superfluous tools for the worried well or the future of patient-led care? I've been skeptical of this version of health care consumerism. It feels more like medicine lite than something truly revolutionary. But as technology improves and care delivery evolves, my mind is changing.

I'm warming to the idea of Biohacker, MD.

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Consumer Wearables

When it launched, the Apple Watch was a solution in search of a problem. The device was a fashion accessory with no clear use case. Today, the Watch is a central piece in Apple's larger health care strategy. Each iteration of the device and its software (watchOS) brings new health features. Soon, sleep apnea detection will join existing capabilities like fall detection, sleep tracking, and arrhythmia alerts. Rumors suggest Apple is working on blood pressure measurement and, the Holy Grail of wearables, blood glucose monitoring (which also happens to be an incredibly difficult engineering problem). The Watch continues to blur the line between consumer wearable and medical device.

I've been an Apple Watch wearer for years, in part because I'm a tech nerd and in part because I enjoy its fitness features. Has the device made me healthier? Maybe. "Closing the rings" is a motivator and creates a sense of accomplishment. I'm more mindful of my activity levels because of the Watch. But many of its features are too subtle or of questionable utility. While sleep tracking is intriguing, wearing the Watch in bed is uncomfortable. I find it's easier to charge my Watch overnight.

TBH, I'm left wanting more actionable insights from the Watch. Nudges are ... fine. Trends in movement, stand, and exercise levels are mildly helpful. watchOS 11 brings a new Vitals app that promises to better contextualize the various data points collected by the Watch. Unfortunately, the Vitals app requires wearing the Watch overnight. Tracking workouts is great, but I'm left wanting more.

To that end, I recently bought an Oura Ring. (Then quickly returned it to order the newly announced Ring 4.) A ring form factor offers advantages. It's easier to wear at night, doesn't need to be charged as often, and doesn't come with a distracting screen or constantly buzzing haptics. In my short time with the Oura Ring 3, I was impressed with how it converts data into actionable insights. A couple of weeks ago, I experienced two nights of terrible sleep — one when I was on call and another when I took a late flight. The Oura Ring detected these variances and gave some helpful suggestions on how to improve my readiness and resilience.

As I get older, I'm mindful of the impact my physical, high-stress job as a joint replacement surgeon has on my overall health. Quantifying these metrics and tying them to things I can modify — sleep, exercise, and meditation — is useful. The Oura Ring isn't quite as good as the Watch when it comes to exercise tracking as it's not comfortable to wear while lifting weights. Fortunately, the Oura software integrates nicely with iOS and Apple Health. Together the Watch and Ring form a helpful (if expensive) duo. [Editor’s note: Could Oura be an acquisition target for Apple?]

Consumer wearables offer a unique value proposition — providing actionable data to support a better understanding of personal health trends. This isn't revolutionary — but it doesn't need to be. Maybe someday we'll get blood sugar monitoring, and these devices will become even more powerful. In the meantime, insights that drive small changes have additive health effects. Knowledge is power. Can't wait for my Ring 4.

Executive Physicals

What's an executive physical? Well, it has "executive" in the title, so you know it's expensive, secretive, and inaccessible! Imagine paying top dollar to have unfettered access to a multiday, comprehensive, personal health evaluation by a panel of distinguished clinicians from a host of medical specialties. You're poked, prodded, and scanned by the best of the best. Your workup includes a battery of blood tests, imaging studies, and health screenings. If they can't find anything, it's not from a lack of looking.

As "consumers" (i.e., patients) become increasingly frustrated with the inaccessibility of comprehensive health care, the appeal of executive physicals is growing. Put another way, they're not just for executives anymore. Offshoots like functional and integrative medicine aim to provide a holistic picture of health that considers factors often overlooked by traditional medicine. Along with executive physicals, so-called "lifestyle medicine" emphasizes prevention, early detection, and alternative methods of health maintenance.

There are downsides. Executive physicals cost anywhere from $2,500 to $10,000 out of pocket. They can lead to overdiagnosis and overtreatment. And, despite their comprehensive nature, they may offer little benefit. Japan's version of executive physicals, called Ningen Dock, is a well-established system of comprehensive health screenings. Some aspects of the program are legally mandated and covered by insurance. Does it work? Ningen Dock has been credited with Japan's high life expectancy by focusing on prevention, early detection, and early intervention. But recent data suggest Japan is falling behind other countries when it comes to screening-related cancer survival rates.

Despite their drawbacks, there are lessons to be learned from executive physicals. Comprehensive, whole-person care should be accessible to all, not some unachievable ideal or executive perk. Unfortunately, despite all the talk of integrated delivery networks, clinically integrated health systems, and medical home models, we struggle to deliver comprehensive care. For all the talk of value-based care, payment mechanisms don't do enough to incentivize its widespread adoption. By taking what's good about executive physicals (their comprehensive nature) and stripping away the low-value, low-yield components, we can offer something worthwhile.

Whole-Body MRI

Whole-body MRIs offer a tantalizing promise: a comprehensive view of the entire body in a single test with the ability to identify diseases in their earliest stages. For patients anxious about their health, this can seem like a powerful preventive measure. Several companies now offer whole-body MRIs including Prenuvo, Ezra, and Forward. Like executive physicals, whole-body MRIs are controversial. Concerns center around overdiagnosis, overtreatment, and lack of evidence to support their widespread use.

I've been told that Prenuvo offers free scans to physicians. I'm still not sure I'd take them up on that offer. As a medical professional, I'm comfortable with incidental findings — or so I think. If my MRI detected bulging discs, small diverticula, or clinically insignificant solid organ cysts, I think I'd be OK with it. But what if there were less certain findings? How far would I go for peace of mind? Is a whole-body MRI equally as likely to hurt me as it is to help me? I'm just not sure.

Studies suggest that such scans are low-yield and cost-ineffective. There's little to no evidence that they're beneficial for standard-risk patients. The "Choosing Wisely" campaign recommends against using whole-body scans for early tumor detection in asymptomatic patients. Routine scans have a high prevalence of incidental findings and false positivity. Negative scans may create a false sense of security. Whole-body MRIs have become a flash point of disagreement between the medical community and biohackers/VC-backed tech companies. Docs decry the low-value nature of the tests and lack of data to support their use. Techies and venture capitalists accuse clinicians of trying to gatekeep care. Is there a role for these scans?

I'm not sold on whole-body MRIs ... yet. However, with enough data and validated AI models, the utility of these tests could improve significantly. We may eventually get to a future where incidental findings don't lead to overdiagnosis and unnecessary workups. Eventually we may be able to predict with a high degree of certainty who would benefit from these scans. But it's going to take a lot of data and well-developed algorithms. Companies offering whole-body MRIs could strengthen their value proposition by being open and transparent. Reporting their results, positive or negative, would go a long way to legitimizing the use of whole-body MRI. Maybe I'll eventually get in the tube, if only to experience what many of my patients do.

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Consumerism in health care is gaining steam. Patients want better access, more control, and additional insights. The elephant in the room is that wearables, executive physicals, and whole-body MRIs are expensive options available primarily to the worried well. Controversies surrounding them are very much First World health care problems. But there are lessons the traditional health care system can learn here. Will we ever get to a point where the value proposition of wearables, comprehensive physicals, and whole-body scans extends to the broader health care system? I think so.

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Ben Schwartz, MD, MBA

Editor-in-Chief, The Surgeon’s Record

Commons Clinic Senior Clinical Fellow