The following essay wasn’t easy to understand. I had trouble taking it in at first. But the beauty of these ideas began to shine through for me when I took time to absorb them. Maybe you will struggle with them a bit yourself.
In his essay, the author argues that if providers focus on “N of 1” it could change healthcare permanently. I think he might be right, or at least makes a good case. It’s a complex argument but worth following to the end. Trust me, the journey is worth taking.
The mysterious @CancerGeek
Before I share his ideas, I’ll start with an introduction to @CancerGeek, the essay’s author. Other than providing a photo as part of his Twitter home page, he’s chosen to be invisible. Despite doing a bunch of skillful GoogleFu, I couldn’t track him down.
@CancerGeek posted a cloud of interests on the Twitter page, including a reference to being global product manager PET-CT; says he develops hospital and cancer centers in the US and China; and describes himself as an associate editor with DesignPatient-MD.
In the essay, he says that he did clinical rotations from 1998 to 1999 while at the University of Wisconsin-Madison Carbone Comprehensive Cancer Center, working with Dr. Minesh Mehta.
He wears a bow tie.
And that’s all I’ve got. He could be anybody or nobody. All we have is his voice. John assures me he’s a real person that works at a company that everyone knows. He’s just chosen to remain relatively anonymous in his social profiles to separate his social profiles from his day job.
The N of 1 concept
Though we don’t know who @CancerGeek is, or why he is hiding, his ideas matter. Let’s take a closer look at the mysterious author’s N of 1, and decide for ourselves what it means. (To play along, you might want to search Twitter for the #Nof1 hashtag.)
To set the stage, @CancerGeek describes a conversation with Dr. Mehta, a radiation oncologist who served as chair of the department where @CancerGeek got his training. During this encounter, he had an insight which helped to make him who he would be — perhaps a moment of satori.
As the story goes, someone called Dr. Mehta to help set up a patient in radiation oncology, needing help but worried about disturbing the important doctor.
Apparently, when Dr. Mehta arrived, he calmly helped the patient, cheerfully introducing himself to their family and addressing all of their questions despite the fact that others were waiting.
When Dr. Mehta asked @CancerGeek why everyone around him was tense, our author told him that they were worried because patients were waiting, they were behind schedule and they knew that he was busy. In response, Dr. Mehta shared the following words:
No matter what else is going on, the world stops once you enter a room and are face to face with a patient and their family. You can only care for one patient at a time. That patient, in that room, at that moment is the only patient that matters. That is the secret to healthcare.
Apparently, this advice changed @CancerGeek on the spot. From that moment on, he would work to focus exclusively on the patient and tune out all distractions.
His ideas crystallized further when he read an article in the New England Journal of Medicine that gave a name to his approach to medicine. The article introduced him to the concept of N of 1. All of the pieces began to began to fit together.
The NEJM article was singing his song. It said that no matter what physicians do, nothing else counts when they’re with the patient. Without the patient, it said, little else matters.
Yes, the author conceded, big projects and big processes matter still matter. Creating care models, developing clinical pathways and clinical service lines, building cancer centers, running hospitals, and offering outpatient imaging, radiology and pathology services are still worthwhile. But to practice well, the author said, dedicate yourself to caring for patients at the N of 1. Our author’s fate was sealed.
Why is N of 1 important to healthcare?
Having told his story, @CancerGeek shifts to the present. He begins by noting that at present, the healthcare industry is focused on delivering care at the “we” level. He describes this concept this way:
“The “We” level means that when you go to see a physician today, that the medical care they recommend to you is based on people similar to you…care based on research of populations on the 100,000+ (foot) level.”
But this approach is going to be scrapped over the next 8 to 10 years, @CancerGeek argues. (Actually, he predicts that the process will take exactly eight years.)
Over time, he sees care moving gradually from the managing groups to delivering personalized care through one-to-one interactions. He believes the process will proceed as follows:
- First, sciences like genomics, proteomics, radionomics, functional imaging and immunotherapies will push the industry into delivering care at a 10,000-foot population level.
- Next, as ecosystems are built out that support seamless sharing of digital footprints, care will move down to the 1,000-foot level.
- Eventually, the system will alight at patient level. On that day, the transition will be complete. Healthcare will no longer be driven by hospitals, healthcare systems or insurance companies. Its sole focus will be on people and communities — and what the patient will become over time.
When this era arrives, doctors will know patients far more deeply, he says.
He predicts that by leveraging all of the data available in the digital world, physicians will know the truth of their experiences, including the food they eat, the air they breathe, how much sleep they get, where they work, how they commute to and from work and whether they care for a family member or friend, doctors will finally be able to offer truly personalized care. They’ll focus on the N of 1, the single patient they’re encountering at that moment.
The death of what we know
But we’re still left with questions about the heart of this idea. What, truly, is the N of 1? Perhaps it is the sound of one hand clapping. Or maybe it springs from an often-cited Zen proverb: “When walking, walk. When eating, eat.” Do what you’re doing right now – focus and stay in the present moment. This is treating patients at the N of 1 level, it seems to me.
Like Zen, the N of 1 concept may sound mystical, but it’s entirely practical. As he points out, patients truly want to be treated at the N of 1 – they don’t care about the paint on the walls or Press Ganey scores, they care about being treated as individuals. And providers need to make this happen.
But to meet this challenge, healthcare as we know it must die, he says. I’ll leave you with his conclusion:
“Within the next eight years, healthcare as we know it will end. The new healthcare will begin. Healthcare delivered at the N of 1.” And those who seek will find.