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Features May 2007: Volume 4, Number 2

The Changing Face of Health Care
By Chistopher Vaughan

UC San Diego Health Care is bringing together a wide spectrum of disciplines and innovative research from genetics to bioengineering, and "translating" research findings into treatments.

While the incidents that took place in spring 2010 were painful, they may have been necessary for our growth. There has been a very positive response from students, faculty and staff, and there is an increased understanding of the importance of diversity, equity and inclusion to our success.

We are, undoubtedly, in the middle of a health care revolution. It is a revolution driven by a confluence of disciplines and innovative research that includes genetics, accelerated drug discoveries, bioengineering, digital and wireless monitoring and, above all, a generation of doctors who skillfully "translate" research findings into treatments. From non-invasive surgery to telemedicine, medical frontiers are fast becoming daily medical practice. And surgeons, engineers, scientists and designers find themselves working together in a new medical paradigm.

These features on the changing face of the UC San Diego Health System, are not just about the application of new technologies—they are about the medical teams who are leading this revolution and sharing it with their patients.they are about the doctors and student doctors bringing medicine to the streets and to our less-fortunate citizens. It is about the education of our next generation of doctors. they are a reflection of UC San Diego's continual pursuit of excellence and innovation in all of its disciplines.

The embryonic future of health care in San Diego can be found in an industrial park about three miles east of campus. In one of these plain, utilitarian buildings housing plastics companies and trucking firms, architects are supervising the construction of high-tech birthing rooms and advanced surgical suites. But these facilities will never see a single patient; they are merely the ghosts of things to come. Nothing here is functional—everything in these rooms is without color, lightweight and can be crushed between the fingers—because every hospital bed, wall, sofa, surgical table and endoscopic video monitor is made of precision-cut polystyrene foam. Like a science-fiction movie set, it simulates a future world: the nearly half-million-square-foot Jacobs Medical Center, which is slated to increase the capacity of the UC San Diego Health System by nearly 50 percent when it opens in 2016.

For months, teams of nurses, physicians and other medical specialists have been touring the facility, pantomiming surgeries, rounds or deliveries, providing feedback on design elements that either will or will not work in the real world. The aim is to ensure that the rooms are comfortable for patients and their family members, while also functioning optimally for their care-giving team. "This is the first time such an elaborate simulation has been done for a hospital," says architect Cheryl Fedorchak, project manager of the simulation. "It's led to some real changes in the design of the rooms."

The architects not only anticipate the future design, but also future technology. "This whole wall will be a combination data display and video screen," Fedorchak says. "We don't have the technology now, but we think it will exist in five years."

Projecting a possible future and preparing for it now, is critical for the UC San Diego Health System. This is not only because the Health System is growing rapidly, but because the world of medicine is changing at a pace greater than at any time since Pasteur and Lister introduced germ theory.

This is all being driven by the urgent knowledge that medicine must change. In the near future, existing models for care will no longer be sustainable (and some would argue they are unsustainable already). "We are confronting significant budget challenges that will likely persist for years to come. And at the same time, we are aging as a nation," says Thomas McAfee, M.D., dean of Clinical Affairs and interim CEO of the UC San Diego Health System. "Everybody hopes for and expects more and better health care—using fewer resources."

Luckily, major technological changes in electronics, computer science, bioscience, bioengineering, robotics and drug development are coming together in a way that will make that possible. And yet another major change is occurring in medicine: people are collaborating in new ways. Physicians and nurses trained in diverse specialties are working more closely together in teams to manage complex treatments. Basic scientists and clinicians are collaborating more directly to speed the transition from the laboratory to the clinic. Patients themselves are communicating more frequently with their caregivers and with each other. These changes not only make it possible to deliver more for less, but are revolutionizing how health is monitored and managed by physicians, patients and everyone in between. And universities are where these social and technological currents blend most efficiently. As David A. Brenner, vice chancellor for Health Sciences and dean, UC San Diego School of Medicine, said in a recent interview, "academic medicine is the major force for innovation in health care."

Personalized Medicine
Through much of the history of modern medicine, the patient has sometimes felt stuck in an impersonal machine. In his book, The Emperor of All Maladies, Siddhartha Mukherjee describes cancer surgeons in the early 20th century as being mostly concerned with cutting out every possible refuge for cancer, leaving patients horribly disfigured and often dying of cancer anyway. Such attitudes were captured in the wry joke about the operation that was a success although the patient died.

However, now, the individual patient increasingly takes center stage. Doctors are better able to obtain large volumes of data about their patients, and low-cost genetic testing (for as little as $100) may yield hundreds of gene variants known to be associated with certain diseases. Sequencing an individual's whole genome, which just over a decade ago was possible only after a $3 billion effort, now costs less than $50,000, and will soon cost less than $5,000. This information increasingly allows physicians to craft therapies that fit an individual's own biochemistry.

"We can now sequence the entire genome of a cancer cell and compare that to the sequence of a healthy cell, giving us insight into the chemical pathways that may be altered," says Thomas Kipps, M.D., Ph.D., interim director of UC San Diego Moores Cancer Center. "This is leading to a whole new era of personalized medicine in which we are not just looking at what type of cancer you have, but what type of cancer cells are present and which therapies are most appropriate."

The ability to understand cancer at the cellular and genetic level is leading to new treatment insights, Kipps says. For example, a rare cancer called gastrointestinal stromal tumor (GIST) was notoriously hard to treat until researchers discovered it was vulnerable to an enzyme-based therapy already being used to treat a different kind of cancer known as chronic myelogenous leukemia or CML. Physicians now use the same treatment for both. This is a prime example of how the characteristics of a cancer cell are more important than the broad categories (stomach cancer, blood cancer, liver cancer) that oncologists have traditionally used to describe cancers.

Targeting characteristics of specific cancers is not only more effective, it's also easier on patients who currently have to undergo multiple rounds of chemotherapy in an attempt to find a drug and dosage that works. Custom tailoring treatments, therefore, will also reduce suffering and cut costs.

"The advances in genomic technologies and methods over the past few years are making personalized cancer treatment increasingly possible, something that was not even conceivable a few years ago," says Kelly A. Frazer, Ph.D., professor and chief of the Division of Genome Information Sciences in the UCSD Department of Pediatrics. "As we develop the resources and databases to genetically map and monitor cancer cases, we'll be able to create treatments tailored for each person."

Health: The App
For over a decade, UC San Diego Health System has invested in digitizing health information, and in technology that allows rapid access and communication of that information. This has been so successful that it is regularly named one of the nation's "Most Wired" by Hospitals and Health Networks, a publication of the American Hospital Association. But the hardwiring of health is about to take a giant leap out of the hospital and into the community, a move that will make the digitization of paper records seem as primitive as Edison's phonograph. "What we are going to see is an increasing number of ways in which doctors can monitor their patients remotely," says Thomas McAfee, dean of Clinical Affairs and interim CEO of UC San Diego Health System. The system already plays a lead role in an expansive project called the San Diego Beacon Community collaborative, an innovative partnership of San Diego County health care organizations that uses electronic health records and health-information exchange programs to bring smarter, lower-cost health care to the region.

Data collected by the different partners is kept in a shared, centralized repository. The program will allow for patient identification, message encryption, images delivered to remote sites, and the sharing of health information data between health care providers in the county.

"Through Beacon, local emergency medical services responders may be able to send car-crash photos to trauma physicians via a smart phone, so that they can identify a patient's potential injuries prior to arrival at the emergency room," says Roger Fisher, administrative manager for emergency medical services, San Diego Fire-Rescue Department. And new technologies, including cellular and wireless advances, may also be used to encourage patients to interact using electronic health records to manage their own health.

Medicine's Social Network
Some of the biggest changes going on in medicine might be described as social: how scientists and the many kinds of health care specialists work together, a change that will only be accelerated with the opening of UC San Diego Health System's new medical centers such as the Sulpizio Cardiovascular Center.

"For years, cardiologists and cardiovascular surgeons worked with one another, but you might say at arm's length," says Kirk L. Peterson, M.D., director of the center and a professor of cardiology and medicine at the UC San Diego School of Medicine. "The most important thing about the Sulpizio Cardiovascular Center is that it brings all the personnel and resources together in one place. Now these people are sitting right next to each other, having day-to-day discussions."

Having cardiovascular specialists talk more frequently or easily may seem like a small thing, but it has a huge effect on patient care, Peterson says. Cardiologists and cardiovascular surgeons, for instance, often need to have extensive consultations to decide whether a given patient with narrowing of the coronary arteries is better off with drug treatment, bypass surgery or catheterization. Having the center's four cardiac operating rooms and six heart catheterization labs together in one center, makes everything run more smoothly and efficiently.

The increased interaction of specialists leads to knowledge transfer and innovation. Peterson cites a technique known as transesophegeal echocardiography in which a specialized probe containing an ultrasound transducer at its tip is passed into the patient's esophagus. This usually provides clearer heart images, especially of structures that are difficult to view through the chest wall. "Anethesiologists use this technique, but cardiologists invented it and have been pushing forward with innovations," Peterson says. "Working closely together, there is the opportunity for the transfer of a lot of this knowledge."

Translational Medicine
It used to be that scientists and doctors kept to themselves, working in different places and speaking different technical languages. Now, physicians and scientists are increasingly working together, sometimes side by side in research laboratories, to translate basic research findings into therapies in the clinic. "What truly sets UC San Diego apart are efforts to integrate clinical activities with research in order to provide new insights into disease," says Kipps of the Moores Cancer Center. He adds that UC San Diego Health System is also partnering with bioengineers to develop wireless tools for monitoring patients and doing groundbreaking work in telemedicine, and in the integration of information technology to assess patients. This emphasis on translational medicine has already been yielding benefits at the Moores Cancer Center. "One of the unique aspects of the Center is that we have patient care and research in the same building," says Kipps. "So there's not a day goes by that researchers don't see patients come in. That charges your batteries to find better treatments."

The potential of translational medicine is so enormous that UC San Diego is planning the 300,000-square-foot Altman Clinical and Translational Research Institute building. This new facility, which is slated to open on the La Jolla medical campus in 2015, will support these "bench-to-bedside initiatives."

A New Birth
One of the areas that has experienced radical changes in the relationship between health care providers and patients is the UCSD Birth Center. Although various approaches to natural childbirth and use of midwives have become increasingly popular, the physician community and midwives have usually approached childbirth from different vantage points.

"Most midwives start from the view that childbirth will progress naturally and healthily with little intervention, whereas doctors, because of their training, come from the 'let's find out what's wrong and fix it' vantage point," says Thomas Moore, M.D., chair of the Department of Reproductive Medicine.

There have been various attempts to start freestanding, midwife-driven birthing centers elsewhere, but they all folded, Moore says, because midwives and doctors had trouble working together. "There's discomfort among some physicians with the midwifery approach," Moore adds. "Most often, the midwives' way works out just fine, but if a problem arises, it is reassuring to have the ability to bring all the fix-it firepower the doctors have available—which is why the unique UCSD Birth Center experience is empowering to both the mother and her birthing team."

About 10 years ago, UC San Diego decided to focus on a new model, a midwife-driven "stand-alone" birthing center nestled within a physician-staffed, high-tech obstetrics service. This is the only such dual center in the county, according to Moore.

"The midwife-driven service has a completely separate space and a totally different atmosphere," Moore says. There are birthing tubs, birthing balls, a quiet environment without medical gas lines or other obvious medical devices. "But we can turn on the technology almost instantly if the baby is oxygen-restricted during labor or has weak vital signs at birth. We have a wonderful safety model behind a holistic, midwife-driven environment, and a flawless record of wonderful outcomes here," he adds.

The secret is having clear guidelines about who can be in the more natural, holistic center and who can't. "If a mother has high blood pressure, we explain why a physician-assisted birth is essential for both mother and baby," Moore says. Another key is having midwives and doctors who are committed to the philosophy behind the center and respectful of one another's methods. This means having an open dialogue between them reinforced by monthly case conferences so that each team knows what the other is doing.

When the new Jacobs Medical Center opens in a few years, the birthing center will occupy prime real estate on the top floors—a symbolic crowning of a cooperative model of medicine that is now taking hold. "It will be spectacular, with the best rooms, a family gathering center and views out over the Pacific," Moore says.

But the best views of all may be of the future. It seems hard to believe that fewer than 25 years ago there was no real Internet, no social media, no Facebook, no streaming movies-on-demand or smart phones with every conceivable app. When the babies born in those rooms at the Jacobs Medical Center grow up to have children themselves, they may look back with equal disbelief at the primitive state of medicine in the early 2010s.

Christopher Vaughan is an author and journalist who focuses on science and medicine.