By DAVID SHAYWITZ<\/p>\n
Our current system of delivering care is awful from the perspective of seemingly every stakeholder. It frustrates, enrages, saddens, and depletes patients and physicians alike. No one designed it this way. It evolved through a series of choices and contingencies that perhaps made sense at the time but now seem to have led us down an evolutionary dead end.<\/p>\n
While there\u2019s no shortage of examples, I was especially struck by an anecdote I heard<\/a> in Dr. Lisa Rosenbaum\u2019s brilliant \u201cNot Otherwise Specified\u201d podcast series for the NEJM<\/em>. Her focus this season is primary care, and in one episode she speaks with a Denver family physician named Larry Green.<\/p>\n \u201cI practiced in the oldest family practice in Denver, for years,\u201d Green explains. \u201cI was the chair of that department, I directed that residency, and I\u2019m now a patient in that practice. I cannot call it. It\u2019s impossible. Because when I call the practice, I get diverted to a call center\u2026\u201d<\/p>\n From the perspective of what he calls the \u201cmedical-industrial complex,\u201d he says, longitudinal relationships are \u201ctotally unimportant in healthcare.\u201d<\/p>\n Yet these relationships \u2013 developed with care over time \u2013 tend to be what many patients crave and what effective doctoring typically requires.<\/p>\n Green\u2019s experience won\u2019t surprise anyone who has tried to get care lately. In November 2023, Mass General Brigham announced<\/a> it would not be accepting new primary care patients. At hospitals everywhere, it\u2019s not unusual for patients to spend hours on gurneys in emergency-department hallways, waiting for an inpatient bed.<\/p>\n I don\u2019t know many physicians who haven\u2019t<\/em> struggled to get care for themselves or a loved one \u2013 often at the very institutions where they trained and to which they\u2019ve devoted years of their lives. If even insiders can\u2019t reliably access timely, compassionate care, what chance does anyone else have?<\/p>\n The miserableness of the system has been well documented, and physician burnout has sadly become a dog-bites-man story.<\/p>\n Applicants Are Still Flocking to Medical Schools<\/strong><\/p>\n What\u2019s perhaps more surprising is how many people are still desperate to enter the system and become physicians, fueling an application process that, as Drs. Rochelle and Loren Walensky have documented<\/a> in The New England Journal of Medicine (NEJM)<\/em>, has become increasingly competitive, expensive, and time-consuming. Premed students routinely take an extra year (or more) to tick all the expected boxes and jump through the hoops that are perceived as mandatory.<\/p>\n This highlights something that\u2019s easy to forget: the ideal of medicine remains deeply attractive. I wrote<\/a> about this almost thirty years ago in a New York Times<\/em> op-ed, and it\u2019s still true today.<\/p>\n The notion of doctoring \u2013 of being trusted at the intersection of science and human stories \u2013 retains a powerful hold on young people. If only the actual experience could live up to the hope of these applicants, the well-worn quotes from Osler and Peabody, the promise of the profession, and the expectations of patients.<\/p>\n Searching For A Better Alternative<\/strong><\/p>\n The idea that there must be a better alternative is at once familiar and evergreen.<\/p>\n <\/span><\/p>\n If you\u2019re a cynic, you channel Homer Simpson<\/a> and conclude, \u201cWe tried our best and failed miserably. The lesson is: never try.\u201d<\/p>\n I see it differently.<\/p>\n The persistence of attempts to build something better \u2013 despite repeated disappointment \u2013 captures both how entrenched the current flawed system is and how deeply people yearn for something appreciably better.<\/p>\n At this point, I don\u2019t know many people who seriously expect incumbents \u2013 whether health systems or their core technology vendors \u2013 to deliver radical change. Most are too busy trying to squeeze more juice from the existing machinery to welcome disruption.<\/p>\n Without a meaningful incentive, you wouldn\u2019t expect organizations exquisitely tuned to the current equilibrium to dismantle or restructure it.<\/p>\n Even so, some of the most committed innovators I know are doubling down inside health systems, trying \u00a0heroically \u2014 like George C. Scott\u2019s beleaguered chief of medicine in The Hospital<\/em> \u2014 to wrestle these institutions back toward the care they were meant to provide.<\/p>\n Others are exploring promising paths outside.<\/p>\n Starting With an Obvious Gap: Preemptive Care<\/strong><\/p>\n In the absence of an established alternative, many patients \u2013 and many doctors \u2013 are trying to assemble at least components of a better system. For a lot of people, that begins with focusing on an aspect our existing system overlooks and undervalues: preemptive care \u2013 sustaining our health rather than simply caring for our illness.<\/p>\n As I recently discussed in a Wall Street Journal<\/em> op-ed<\/a> and at a Harvard Business School panel on healthy aging, the current fascination with \u201clongevity\u201d sits on top of something more interesting than recovery pods and rejuvenation Olympics<\/a>. It\u2019s easy, and appropriate, to roll your eyes at anti-aging drips and supplement stacks.<\/p>\n Underneath the spectacle, though, I\u2019ve been struck by a quieter shift.\u00a0 More people seem to believe that the deterioration they\u2019ve observed in older relatives, friends, and cherished mentors isn\u2019t inevitable, and they\u2019re organizing their lives accordingly \u2014 an effort, in Bart Giamatti\u2019s phrase<\/a> (riffing on Milton), to fend off \u201cthe ruin of our grandparents.\u201d<\/p>\n Science has helped here. Geroscience has moved from backwater to frontier, and the message it carries is surprisingly simple: movement, sleep, decent food, and warm human connection are not lifestyle accessories, they\u2019re central levers of healthy aging. GLP-1 medicines, as I described in STAT<\/em> this summer<\/a>, have added an unexpected assist, giving many people who\u2019d been defeated by years of yo-yo dieting a first experience of real traction.<\/p>\n At the same time, advances in measurement have made the body feel newly legible. Population-scale data have given rise to ideas like \u201cbiological age\u201d \u2013 an assessment approach not yet validated for clinical use in individuals, but powerful in the story they tell.<\/p>\n Concepts like \u201cbiological age\u201d invite people to see aging as at least partially malleable, as something you can potentially inflect.<\/p>\n Even some of the more dubious offerings \u2013 supplement rituals, for example \u2013 often function less as biochemistry and more as daily expressions of intent.<\/p>\n In the op-ed, I argued that this is the real through-line: a refusal to retreat passively into decline, and a growing appetite for preemptive moves that might tilt the odds, even a little, in our favor.<\/p>\n Aspiring Longevity Contenders: Fitness, Wearable, & Testing Companies<\/strong><\/p>\n Not surprisingly, this perceived opportunity has attracted several categories of companies into the \u201chealth\u201d space. You can roughly sort them into three overlapping buckets:<\/p>\n Fitness<\/strong> platforms like Peloton and Tonal that started as movement motivators and now increasingly wrap their offerings in a longevity narrative.<\/p>\n Wearable<\/strong>-centric companies like Oura and Whoop that focus on performance metrics around activity, strain, and recovery, again increasingly framed as healthy-aging tools.<\/p>\n Comprehensive testing platforms<\/strong> like Function Health, Superpower, and others, which offer large batteries of laboratory tests (often accompanied by imaging) marketed as opportunities to identify vulnerabilities early.<\/p>\n All of these companies are working feverishly on AI-enabled data plays and promise some version of personalized recommendation. Many are led by serious people who genuinely want to help.<\/p>\n Yet taken as a group, they also reveal the limits of an engineering mindset applied to human flourishing.\u00a0 As I argued in a recent STAT<\/em> column<\/a>, we\u2019ve become very good at harvesting data and building dashboards, and much less good at building platforms that support the experience of living a fuller, more agentic life.<\/p>\n Fitness & Wearable Companies: An Obsession with Performance Metrics<\/strong><\/p>\n Today\u2019s digital health tools, as I discussed<\/a> in the Boston Globe<\/em> this summer, tend to optimize what\u2019s easy to count and, in the process, miss what most of us actually value: connection, purpose, and the sense that our choices are beginning to add up.<\/p>\n The fitness and metric-heavy companies also illustrate a classic analytic trap (\u201csurvivorship bias<\/a>\u201d) that has been on my mind a lot lately \u2013 the \u201cairplane problem.\u201d (Image source: Wikipedia.)<\/p>\n During World War II, analysts studying bombers returning from missions noticed that certain parts of the planes were riddled with bullet holes, and proposed adding armor to those areas. Statistician Abraham Wald pointed out the mistake: the bullet holes marked the places a plane could be hit and still make it home. The planes that didn\u2019t return had likely been hit elsewhere. That\u2019s where the armor was needed.<\/p>\n Most fitness and wearable companies are obsessed with retaining the people who already sign up \u2013 generally highly engaged, data-hungry users who enjoy tracking their VO\u2082 max, heart-rate variability, and step counts. These are the planes that make it back.<\/p>\n What these companies don\u2019t see are the people who try once or twice, feel judged or overwhelmed or bored, and bounce off \u2013 people like New York Times<\/em> op-ed contributor Rachel Feintzeig, who memorably describes<\/a> her exercise experience:<\/p>\n \u201cI get on my Peloton and am confronted with a veritable dashboard of my inadequacies: cadence (sluggish), resistance level (embarrassing), output (am I even alive?). There is my prior, surely eternal, personal record, highlighted so that I never forget exactly how much better I was three years ago. Suddenly I\u2019m grappling with the passage of time, in my basement, as an Instagram influencer in a coordinating spandex set beseeches me to pedal faster.\u201d<\/p>\n People like Feintzeig \u2013 and those who never even bother with platforms like Peloton \u2013are the missing planes, as well as the untapped opportunity.<\/p>\n Early on, I was drawn to the idea of starting with movement as the foundation for a broader vision of flourishing, in part because it\u2019s so concrete, palpable, and obviously useful for health on its own terms, even before it connects to anything deeper.<\/p>\n It reminds me of the famous exchange<\/a> from Woody Allen\u2019s 1975 film Love and Death<\/em>:<\/p>\n Sonja<\/strong> (Diane Keaton): \u201cSex without love is an empty experience.\u201d Movement without any larger sense of meaning can feel a bit like that. Even if it doesn\u2019t yet connect to purpose, agency, or community, it\u2019s still one of the healthier \u201cempty experiences\u201d we have \u2013 especially for those who aren\u2019t exercising at all, since the health benefits of going from nothing to something<\/a> can be as significant as going from something to a lot more.<\/p>\n I still think movement is a great place to start.<\/p>\n Unfortunately, I don\u2019t see much (any) evidence that today\u2019s fitness platforms view longevity as more than a marketing gloss, or that they are preparing seriously to serve the far larger group of people who want to lead richer lives, not dominate reductive leaderboards.<\/p>\n At the end of the day, it seems, fitness companies are gonna fitness. The longevity branding is kosher-style at best, and often closer to a BLT on a bagel.<\/p>\n Comprehensive Testing Companies: False Positives & Sterile Precision?<\/strong><\/p>\n The comprehensive testing companies raise a different set of concerns. Large panels of lab tests and imaging sound appealing \u2013 who wouldn\u2019t want to \u201cknow everything\u201d and catch problems early?<\/p>\n In practice, as Dr. Eric Topol has critically reviewed<\/a> at Ground Truths<\/em><\/a>, the risks of false positives and incidentalomas are substantial, especially when testing is decoupled from clear, evidence-based action plans.<\/p>\n I\u2019ve spent years following the arc from genetics to \u201cpersonalized\u201d to \u201cprecision\u201d medicine and since high school have been deeply engaged in the science. I have a real appreciation for the promise, as well as for the practical limitations.<\/p>\n I recognize that the opportunities for truly precise, individualized interventions tend to be wildly overstated<\/a> \u2013 even the ones that don\u2019t come bundled with the hard sell of supplements.<\/p>\n The same goes for metabolomic and nutritional profiling. As Kevin Hall and others have pointed out<\/a>, much of what\u2019s been sold as precision nutrition turns out to be better marketing than science.<\/p>\n So where are the rays of hope?\u00a0 Mostly, they center around talent as much as vision.<\/p>\n Green Shoot 1: Talent Redefining Testing Companies<\/strong><\/p>\n When Function Health announced its recent fundraise<\/a>, most of the attention focused on the celebrity investors and marketing sizzle.<\/p>\n What caught my eye was something else entirely: the decision by Dr. Daniel Sodickson<\/a> \u2013- a serious scientist and imaging innovator, long a leader in MRI at NYU, and recently an author<\/a> \u2013- to join as Chief Medical Scientist.<\/p>\n Dan, also a medical school classmate and friend, is the opposite of a hype merchant. He is thoughtful, technically deep, and obsessed with context and longitudinal understanding. His move signaled to me that Function was serious about building an engine for interpreting multimodal, longitudinal data in a way that could, over time, support genuinely more precise, personalized recommendations.<\/p>\n This aligns closely with ideas the exceptionally innovative medical scientists Lee Hood and Nathan Price have been articulating for years (including in their visionary 2023 book, The Age of Scientific Wellness<\/em><\/a>), and that efforts like Arivale tried to operationalize<\/a>. I\u2019m excited about this direction and have been working with Dan and Nathan on some of these concepts \u2013 stay tuned.<\/p>\n Green Shoot 2: Talent Focused on Leveraging Agency & Personal Health Data<\/strong><\/p>\n A second source of energy and inspiration for me, also connected to talent, has been the caliber of physicians and physician\u2013scientists who\u2019ve reached out to me as I\u2019ve been developing and championing the concept of agency as the \u201cmotivational currency of behavior change,\u201d ideas provisionally, and loosely, organized at KindWellHealth<\/a>. \u00a0<\/p>\n In just the last few weeks, I\u2019ve heard from clinicians, informatics leaders, former regulators, and population-health experts who said some version of: \u201cYour focus on agency is exactly what I\u2019ve been circling; I\u2019m trying to build my next chapter around something like this.\u201d<\/p>\n These are not people chasing the latest wellness fad. They are serious medical innovators who care deeply about science and patients and are trying to find a way to enhance health that feels truer to both, supported by rigorous, credible evidence.<\/p>\n One direction this naturally leads is towards a health system built around a data-empowered person who becomes the central locus of both control and information. In this vision, you would control your data the way you control your money. You might have accounts at many institutions, but you see everything in one place and can direct it where you want.<\/p>\n This idea has been around for a while, but it has acquired new urgency as patients are increasingly handed more responsibility without real visibility.<\/p>\n A personal \u201chealth data cloud\u201d (Nathan Price has been using the more expansive phrase, \u201cpersonal, dense, dynamic\u00a0data\u00a0cloud\u201d) isn\u2019t a cure-all, but it feels like it could be a vital first step towards a more enlightened, informed, person-centric, and humane health future.<\/p>\n It\u2019s important to emphasize that \u201cperson-centric\u201d doesn\u2019t mean a series of dispassionate transactions with healthcare providers, which arguably is already the status quo. Nor does it mean dumping a stack of options and PDFs on patients and congratulating ourselves for \u201cempowering\u201d them.<\/p>\n As Atul Gawande has described so eloquently, in appropriately pushing back against medical paternalism, the pendulum in some settings has swung too far the other way.<\/p>\n Some physicians, trying to be sensitive, have misunderstood the assignment. They present a neutral menu and maintain distance at moments when some patients are desperate for a clinician to share the decision-making burden \u2013 to listen carefully, offer a considered recommendation, and shoulder some of the responsibility.\u00a0<\/p>\n
Boris<\/strong> (Allen): \u201cYes, but as empty experiences go, it\u2019s one of the best.\u201d<\/em><\/p>\n