“Things are only impossible until they’re not.”- Captain Jean-Luc Picard
Exposome Perspectives Blog by Robert O. Wright, MD, MPH
The hardest part was getting there. The commuter train was late. Al Huxley, a nondescript middle-aged man plagued by a sweet tooth, kidney failure and type 2 diabetes, although perhaps not in that order, pushed the elevator button 14 times, even though the light was already on. He was always punctual and being late for his nephrology appointment did not sit well with him. As he entered the glass doors, he was relieved to notice the waiting room was nearly empty. The unit secretary greeted him very professionally “Are you Thomas More, here for the 10:30 appointment?” “No, my name is ‘Huxley’, I’m the 10 o’clock appointment, the train was very late, some sort of breakdown that blocked the tracks.” He was about to add more detail about the age of the commuter train fleet and the collapse of societal investment in infrastructure, but was interrupted. “No problem, could we have your cellphone please, it will only take 2 minutes”. He handed her the phone over the white fiberglass counter and watched as she plugged into its port and typed on the computer terminal. “Dr. McCoy is running a little ahead today actually, and it looks like we have the results of the blood, urine, and hair analysis you dropped off yesterday. Thank you for coming to the lab in advance. It helps to have the results for the ‘in-person’ visit.” He remembered when he first started coming here for kidney failure 10 years ago, the contrast was so stark – it’s a new world he thought to himself.
After a few minutes the nurse called his name. In the exam room, she took his blood pressure, checked his heart and respiratory rate, then measured his weight and body fat percentage with equipment that logged all results directly to his electronic health record. She administered a brief computerized cognitive test and a questionnaire on depression and anxiety on a handheld tablet. He tried to make small talk. “You know, I knew Dr. McCoy when he was a kid, went to school with my son–he went by Lenny back then, but I always called him ‘Leonard’.” As he spoke, his data from the exam, lab tests, and his smart watch were uploaded to a cloud-based data platform and linked with curated databases that catalogued all the health impacts of the known environment–chemicals, diet, social measures, air and water quality, etc. calibrated to his age and for patients with diabetes and renal failure. His chemical and nutrient screens from his lab tests, information from his occupation, neighborhood, house, and demographics (i.e. age, gender, income) were analyzed on the mainframe computer to create a health risk profile.
Years ago, at Mr. Huxley’s first visit to Dr. McCoy, his DNA was sequenced and all the genetic variants he carried were catalogued. Since then, at every visit, his smart watch data was uploaded to the system. His work history was linked to a dataset on occupational health risks that estimated past work-related chemical exposures, stress levels, physical activity, air exposures and sedentariness. Yesterday, the blood and urine samples he gave were analyzed for chemicals, hormones and food nutrients. The hair samples and heart rate data from his smart watch calculated his circadian rhythms. At his home, an indoor air monitor linked by blue tooth to his cell phone provided data on the air quality and indoor temperature in his apartment. Local data on air pollution, weather, and temperature were linked to the GPS tracking program in his smart watch to precisely estimate the quality of all the air he had breathed in the last 6 months.
As he tapped his fingers on a metal tray, waiting for Dr. McCoy, artificial intelligence (AI) algorithms mapped the quality of his local ‘exposome’ with his weight, blood pressure, mental health and any evidence of mental decline. Hospital computers checked whether he had any genetic variants that may alter the impact of his specific environmental exposures. His regimen of treatment drugs was combined with the environmental data to detect any possible interactions that might impair their efficacy. It was all so fast that the results were ready before Dr. McCoy knocked on the door and entered the room.
Dr. McCoy swung open the door and apologized for keeping him waiting – the average 15-minute doctor visit made his job difficult, especially since medical care was only getting more complicated. The ability to generate computerized risk scores helped immensely. As he scanned the output that estimated Mr. Huxley’s health risk from his personalized exposome, Dr. McCoy told him, “In the old days, we only collected the genome and ignored the exposome. We couldn’t accurately predict anything- my God- it was like the Dark Ages. We should have known better.” He shook his head. “It was so illogical. After all, your DNA never changes – how could it possibly predict when or how your health will change as an adult.” He scanned the tablet’s screen, scrolling through the data summaries and risk scores. “These risk scores helped us diagnose your kidney failure even before we could see it on your lab tests. Since by monitoring your exposome it’s helped us keep its progression in check. We can monitor your diet, air quality and stressors and then recommend adjustments if they affect your health. We used them to adjust your medications, make diet changes, and pointed out potential health issues in your home. Remember how that stove was creating air pollution- we figured out its connection with your kidney failure worsening. That was picked up with just your watch and a home monitor! It’s added years to your life and it’s so fast–exposomics has been a godsend to medicine”.
He frowned as he read the report. The AI output revealed that Mr. Huxley had been taking Over-the-Counter antacids–something he had forgotten to mention to Dr. McCoy or the nurse. “Sorry, I didn’t think it was important,” Huxley told him sheepishly. The antacid contained a chemical that impeded the metabolism of his hypertension medications. This explained a trend toward higher blood pressure in his smart watch data. “We don’t have to adjust your hypertension medicine, we’ll just use an alternative antacid that doesn’t interfere with your medications- much less risk that way.” But there was one more thing as well.
Dr. McCoy tilted his head, raised his left eyebrow and winked, “It looks like you’ve gained weight, but the impedance measures to test for body fat tell us it’s not from water–which can happen with kidney failure. Your weight gain is from…well, let’s just say I would like to better understand the weight gain.” He inflected his voice like a question to be polite, but he knew his patient’s weight gain was from overeating. “I would like to be able to give your specific recommendation on the changes we can make in your diet. Could I get permission to analyze your groceries and diet?” Mr. Huxley agreed and signed a consent form, then handed Dr. McCoy his key chain with the plastic card with the scanning code for his local supermarket. “I will need you to fill out a questionnaire that will help us distinguish your diet from the whole of the groceries your family buys.”
Mr. Huxley thought about it for a moment. That’s a lot of information. Who sees this? Is it really necessary to comb through my groceries? I can tell them what they need to know. “You know,” he said. “On second thought, I think I will forego that. I know what I am eating, and I’ll work with you on changing my diet. I’m not comfortable sharing that much personal information.” Dr. McCoy listened and nodded. The Hippocratic Oath is a prime directive, he thought to himself. “Of course,” he said, “it’s always your choice.” I am going to set you up with a dietician. We’ll do this the old school way.” He tapped a referral link on his tablet and opened his left arm towards the door. Clapping Mr. Huxley on the shoulder, he said “All your kidney labs look great, things are actually going really well. I’ll see you again in six months. We’ll email and text you a link with our written recommendations. If we can get you the monitors to your home, we’ll start using telehealth to save you the trip in. I heard from the front desk you had a rough commute.” As if on cue, Mr. Huxley began a long explanation about the decline of civilization and the need for infrastructure. It coincided with a decrease in blood pressure and heart rate detected by his smart watch. He was venting on the surface, but the data said he was relaxing on the inside.
FIFTEEN MINUTES LATER
“We’re losing him.” Mr. Huxley looked up from the gurney with a puzzled, bruised face and stared into the bright lights of the Emergency Room Trauma Suite. “Where am I?” he groaned. He instinctively raised his arm to look at his Timex watch, the glass case was cracked. He blinked at the nurse wearing a ‘Carter-Mondale 76’ campaign button on her scrubs. “You fell off your bed” she answered. “Your nephrologist gave you a blood pressure medicine that interacts with your diabetes medicine, and you were getting low blood sugar- you’ve been blacking out all week. Can you tell me your name?” She hastily measured his mouth against different sized face masks and connected the best fit to the oxygen tubing. “Huxley” he stammered weakly. “Do you know what year it is, Mr. Huxley?” He paused, thinking of Dr McCoy and his promise for telehealth- “2023, I think”. She looked up at the Attending doctor, holding his neck in place at the top of the gurney. “He’s delirious. He thinks it’s 50 years in the future. We should intubate.” The physician nodded his head. The last thing Huxley remembered was a face mask pushed down on his mouth as the lights went dark. `