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The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health Care [Hardcover]

Eric Topol
4.7 out of 5 stars  See all reviews (3 customer reviews)
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Book Description

Jan. 31 2012 0465025501 978-0465025503 1
What if your cell phone could detect cancer cells circulating in your blood or warn you of an imminent heart attack? Mobile wireless digital devices, including smartphones and tablets with seemingly limitless functionality, have brought about radical changes in our lives, providing hyper-connectivity to social networks and cloud computing. But the digital world has hardly pierced the medical cocoon.

  Until now. Beyond reading email and surfing the Web, we will soon be checking our vital signs on our phone. We can already continuously monitor our heart rhythm, blood glucose levels, and brain waves while we sleep. Miniature ultrasound imaging devices are replacing the icon of medicine-the stethoscope. DNA sequencing, Facebook, and the Watson supercomputer have already saved lives. For the first time we can capture all the relevant data from each individual to enable precision therapy, preventmajor side effects of medications, and ultimately to prevent many diseases from ever occurring. And yet many of these digital medical innovations lie unused because of the medical community's profound resistance to change.   In The Creative Destruction of Medicine, Eric Topol-one of the nation's top physicians and a leading voice on the digital revolution in medicine-argues that radical innovation and a true democratization of medical care are within reach, but only if we consumers demand it. We can force medicine to undergo its biggest shakeup in history. This book shows us the stakes-and how to win them.

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Arnold S. Relman, New York Review of Books
“As an introduction for the lay reader to the sophisticated digital technology now being applied to medical care, and as an explanation of the rapidly advancing science of medical genetics and the new revelations from the sequencing of the human genome, Topol’s book is a tour de force.”

Siddhartha Mukherjee, author of The Emperor of All Maladies: A Biography of Cancer

“What happens when you combine cellular phone technology with the cellular aberrations in disease? Or create a bridge between the digital revolution with the medical revolution? How will minute biological sensors alter the way we treat lethal illnesses, such as heart attacks or cancer? This marvelous book by Eric Topol, a leading cardiologist, gene hunter and medical thinker, answers not just these questions, but many many more. Topol’s analysis draws us to the very frontlines of medicine, and leaves us with a view of a landscape that is both foreign and daunting. He manages to recount this story in simple, lucid language—resulting in an enthralling and important book.” 


Atul Gawande, M.D., author of The Checklist Manifesto
“Dr. Eric Topol is an extraordinary doctor. He’s started a leading medical school, identified the first genes to underlie development of heart disease, led major medical centers, and been a pioneer of wireless medicine. But he is also a remarkable communicator—one of the few top-flight scientists in medicine to be able to genuinely connect with the public. He was, for example, the first physician researcher to question the safety of Vioxx—and unlike most who raise safety questions, actually succeed in bringing the concerns to public attention. I have known and admired Dr. Topol for a long time. I recommend him highly.”
 
A. J. Jacobs, author of My Life as an Experiment and The Year of Living Biblically
“It may sound like hyperbole, but it’s true: Medicine is undergoing its biggest revolution since the invention of the germ theory. As Eric Topol writes, thirty years ago, ‘digital medicine’ referred to rectal examinations. Dr. Topol is both a leader of and perfect guide to this brave new health world. His book should be prescribed for doctors and patients alike.”
 
Steve Case, co-founder, AOL, and founder of Revolution LLC
“Health care is poised to be revolutionized by two forces—technology and consumerism—and Dr. Eric Topol explains why. One-size-fits-all medicine will soon be overtaken by highly personalized, customized solutions that are enabled by breakthroughs in genomics and mobile devices and propelled by empowered consumers looking to live longer, healthier lives. Fasten your seat belts and get ready for the ride—and learn what steps you can take to begin to take control of your health.”
 
James Fowler, Professor of Medical Genetics and Political Science, UC San Diego, and author of Connected
“Eric Topol is uniquely positioned to write such a timely and important book. He leads two institutions—one in genomics and one in wireless health—that will each play a huge role in transforming medicine in the twenty-first century. From this vantage point, he can see unifying themes that will underlie the coming revolution in population and personal health, and he communicates his vision with vibrant energy. Everyone will want to read this book.”
 
Clayton M. Christensen, Robert and Jane Cizik Professor of Business Administration, Harvard Business School, and author of The Innovator’s Dilemma “Eric Topol gives us an eye-opening look at what’s possible in healthcare if people can mobilize to charge the status quo. The Creative Destruction of Medicine is simply remarkable.”
 
Mehmet Oz, M.D., Professor and Vice-Chair of Surgery, NY Presbyterian/Columbia University
“Eric Topol outlines the creative destruction of medicine that must be led by informed consumers. Smart patients will push the many stakeholders in health to accelerate change as medicine adapts to a new world of information and technology.”
 
Jeffrey Immelt, Chairman and CEO of General Electric
“Eric Topol has been a longtime innovator in healthcare. In The Creative Destruction of Medicine, he citesthe big waves of innovation that will save healthcare for the future. Real healthcare reform has not yet begun, but it will.  The Creative Destruction of Medicine lays out the path.”
 
Brook Byers, Partner, Kleiner Perkins Caufield & Byers
“This is the one book to read for a complete and clear view of our medical future, as enabled by the convergence of digital, mobile, genomic, and life science breakthroughs. Dr. Topol explains how iPhones, cloud computing, gene sequencing, wireless sensors, modernized clinical trials, internet connectivity, advanced diagnostics, targeted therapies and other science will enable the individualization of medicine—and force overdue radical change in how medicine is delivered, regulated, and reimbursed. This book should be read by patients, doctors, scientists, entrepreneurs, insurers, regulators, digital engineers—anyone who wants better health, lower costs, and participation in this revolution.”
 
Misha Angrist, Assistant Professor, Duke Institute for Genome Sciences & Policy, and author of Here is a Human Being
“Eric Topol is that rare physician willing to challenge the orthodoxies of his guild. He recognizes that in the U.S., health care business-as-usual is unsustainable.  But he does not despair. He bears witness to the rise of Homo digitus and the promise it holds to upend the inefficiencies and dysfunction so entrenched in clinical medicine. The Creative Destruction of Medicine is a timely tour de force. It is a necessary heresy.”
 
George Church, Professor of Genetics, Harvard Medical School
“What happens when the super-convergence of smart phones further combines with million-fold lower-cost genomics and diverse wearable sensors? The riveting answer leads compellingly to a call to activism—not only for medical care providers, but all patients and everyone looking for the next ‘disruptive’ economic revolution. This future is closer than most of us would have imagined before seeing it laid out so clearly. A must-read.”
 
J. Craig Venter, Chairman and President, J. Craig Venter Institute
“Our sequencing of the human genome eleven years ago was the beginning of the individualized medicine revolution, a revolution that cannot happen without digitized personal phenotype information. Eric Topol provides a path forward using your digitized genome, remote sensing devices and social networking to place the educated at the center of medicine.”
 
Omar Ishrak, Chairman and CEO of Medtronic
“Eric Topol provides an excellent and pragmatic view of the U.S. healthcare system from a patient’s perspective. He then offers, through numerous examples, an exciting vision for the future ... when technology can be used to dramatically improve the quality of care and reduce cost at the same time. The Creative Destruction of Medicine is a highly informative and enjoyable book, which truly triggers the reader’s imagination as to what is possible”
 
Reed Tuckson, M.D., Executive Vice President and Chief of Medical Affairs, UnitedHealth Group
“Eric Topol has written an extraordinarily important book at just the right moment. Drawing upon a unique and impressive array of convergent expertise in medical research, clinical medicine, consumer and health technological advancements, and health policy, Dr. Topol opens the door for an essential discussion of old challenges viewed through an innovative lens. In the context of increasingly unaffordable health care costs, suboptimal quality of care delivery, a tsunami of preventable chronic illness, and new accountabilities for consumer’s health choices and behaviors, this book helps  all of us to think about solutions in new and exciting ways!”
 
Juan Enriquez, Managing Director, Excel Venture Management, and author As the Future Catches You
“Much of the wealth created over the last decades arose out of a brutal transition from ABC’s to digital code. While creating some of the world’s most valuable companies, this process also upended whole industries and even countries. Now medicine, health care, and life sciences are undergoing the same transition. And, again, enormous wealth will be created and destroyed. This book is a road map of what is about to happen.”
 
Elias Zerhouni, M.D., President, Global R&D, Sanofi and former director, National Institutes of Health
“If we keep practicing medicine as we know it today, healthcare will become an unbearable burden. We are in a real race between healthcare innovation and the resistance to change of the medical system. In a comprehensive and well researched tour de force, Eric Topol, always a clear and uncompromising thought leader of his generation, challenges us to imagine the revolutionary potential of a world where medical information no longer belongs to a few and can be automatically collected from the many to greatly improve healthcare for all. This is a must read!”


Kirkus Reviews

“Topol weaves useful knowledge about how to evaluate the choices open to patients into this exciting account of the revolutionary changes we can expect.”




William R. Brody, M.D., Ph.D., President, The Salk Institute for Biological Studies
The Creative Destruction of Medicine is an engaging look into how the discoveries in genetics and biology will change the landscape of medicine. Along the way, Dr. Topol provides a fascinating compendium of stories about the shortcomings of medicine as it is currently practiced and how the revolutionary discoveries coming since the first sequencing of the human genome a decade ago will shape the delivery of healthcare in the 21st century.”

Paul E. Jacobs, Ph.D., Chairman and CEO, Qualcomm Incorporated
“Dr. Topol believes that medicine, catalyzed by extraordinary innovation that exploits digital information, is about to go through its biggest shakeup in history. His newest book calls for a ‘jailbreak’ from the ideas of the past. In the next phase of medicine, powerful digital tools including mobile sensors and advanced processors will transform our understanding of the individual, enabling creative ‘mash-ups’ of data that will spark entirely new discoveries and spawn ultra-personalized health and fitness solutions. And with over 5.7 billion mobile connections worldwide, the mobile technology platform will have a major impact on that vision—leading to what Dr. Topol describes as nothing less than a ‘reboot’ of the health care system. Qualcomm, and its partners all around the world, are working to bring wireless innovations to market that will contribute to the solution. And we share Dr. Topol’s view that individual consumers have the opportunity, and the power, to increase the pace of the titanic change that’s coming.”
 
John Martin, Chairman and CEO, Gilead Sciences
“Eric Topol offers a new and intriguing perspective on how the intersections of medicine and technology could further transform the delivery of healthcare and the role of a patient. He advocates for a future world of medicine where informed consumers are in the driver seat and control their own healthcare based on genomic information and real-time data obtained through nanosensors and wireless technology.”
 
Eric Silfen, M.D., Senior Vice-President and Chief Medical Officer, Philips Healthcare
“In an upbeat, comprehensive volume, Dr. Topol has woven the prevailing technological undercurrents of the post-PC world—its power of many; its Gucci of gadgets; its cloud ecosystem; its ‘Arab Spring’ of apps; and its ubiquitous, calm computing—with the disruptive innovations of biomedicine, to create a compelling account of how this bio-digital transformation will hasten personalization of the highest quality of medical care.”
 
Greg Lucier, CEO, Life Technologies
“Dr. Topol is the top thought leader in medicine today, with exceptional vision for how its future can be rebooted. This book will create and catalyze a movement for the individualization and democratization of medicine—and undoubtedly promote better health care”
 
Dean Ornish, M.D., Founder and President, Preventive Medicine Research Institute, and author of The Spectrum
“Eric Topol is the perfect author for this book. He has a unique understanding of both genomics and wireless medicine and has a remarkable track record as a charismatic pioneer, visionary, and change agent in medicine. I’m sure this book will reach a very large number of people with information that can both empower and help transform their lives for the better.”
 
Nature
“The digital age opens up the possibility of a new type of medicine in which an individual’s health data are digitized using wearable sensors, smartphone apps and genome information, writes geneticist and cardiologist Eric Topol. With this wealth of data, medical interventions could be tailored to our uniqueness. Topol covers failures in patient information; what might happen if genomics, imaging, sensors and better health information were to converge; and the potential pitfalls of this brave new medical world.”
 
New Scientist
“[A]n eye opening account of why conventional medicine is doomed…. [C]ompelling stuff…. [T]he book provides an excellent summary of the current state of medical genetics and how fast it is progressing, with examples that may surprise even those working in medicine.”
 
Wall Street Journal
“The Creative Destruction of Medicine—an allusion to economist Joseph Schumpeter’s description of ‘creative destruction’ as an engine of business innovation—is a venture capitalist’s delight, describing dozens of medical technologies that show great promise. The book also provides colorful anecdotes about Dr. Topol’s own sampling of these products, as both a doctor and stand-in patient…. [The book’s] most important contributions are in portraying how medical innovation will coalesce to change clinical practice and what the coming changes mean for today’s policy debates…. In Dr. Topol’s vision, innovation that enables real-time diagnosis and personalized treatments is a certainty, though not because reluctant or ‘sclerotic’ doctors accept it or because Washington wills it into being. A seductive technology that works like a dream and improves lives will set off a consumer clamor, whether the new tool is an iPhone 4S or an implantable blood-sugar meter.”
 
Nature Genetics
“Deriving inspiration from the economist Joseph Schumpeter, Topol proposes nothing less than the ‘creative destruction’ of medicine as it is currently practiced, replacing it with a brave new world in which interconnected technologies dramatically improve patient outcomes…. [T]he book is an enjoyable, high-level review of the current state of the field, intended for a general audience but referenced for those inclined to read more deeply. With its rich discussion of science and technology and companies specific to the last couple of years, this book certainly has contemporary relevance.”
 
Boston Globe
“Topol does an excellent job of explaining all, and his enthusiasm for the possibilities of what the future holds is infectious. It can only be hoped, as the convergence he so convincingly predicts materializes, that the barriers erected by the gatekeepers of yesterday’s paradigms will be easily dismantled so as not to impede the benefits it promises.”

Forbes
“A must-read that lays out a road map for how new technologies in genomics, information technology, and mobile medicine may completely change the way we treat and prevent illness. It’s highly recommended, because Topol has a unique vantage point: he’s one of the few researchers to have played an important role in the old, mass-market medicine world and the newer, genetically focused one.”

Salon
“Topol demonstrates how the digital revolution can be used to change individual care and prevention, and even the economics of American healthcare. From cell phones that automatically collect medical data, to biosensors, advanced imaging, individualized prescriptions and gene-specific drugs, Topol’s book leads readers through science-fiction-sounding scenarios that may soon be a reality.”
 
Abigail Zuger, M.D., New York Times
“[R]eadable and comprehensive…. [Dr. Topol] dispenses in short order with our current population-based medical strategies. They are wasteful and inexact, he points out, often marginally beneficial to the group and downright harmful to the individual. He presents an array of far better ideas, a few now actually being practiced in rudimentary form.”
 
The Economist
“Eric Topol provides a…look at why medicine is about to be ‘Schumpeterised’ (his word) by digital technology. [This book is] a godsend for those who suffer from Armageddon fatigue. [It] also remind[s] us that technology keeps improving despite economic gloom.”
 
David Ewing Duncan, The Atlantic
“In [The Creative Destruction of Medicine]…Topol blasts current-day medicine as being archaic and wasteful, making his case with a compelling blend of statistics, anecdotes, and barbs aimed at health care’s Ancien Régime…. [Topol] does a good job of explaining subtleties to a lay audience—such as why some genetic testing for predicting disease is valid and useful, and why much is not.”

Wall Street Journal
The Creative Destruction of Medicine…offers an illuminating perspective on the coming digitization of health care.”

The Lancet
The Creative Destruction of Medicine is … packed full of practical examples of how technology is already changing the way some physicians care for patients and patients can monitor themselves…. [the book is] a must read for patients and doctors alike.”

About the Author

Eric J. Topol, M.D. , is professor of innovative medicine and the director of the Scripps Translational Science Institute in La Jolla, California. Trained at Johns Hopkins University, he conducted one of the first trials of a genetically engineered protein for treating heart attacks, and was the founder of the world's first cardiovascular gene bank at the Cleveland Clinic. He lives with his family in La Jolla, California.

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Most helpful customer reviews
5.0 out of 5 stars TOPOL'S BOOK May 12 2014
Format:Hardcover|Verified Purchase
Excellent book that is a good read.
Starts off with lots of technical innovations but loses pace mid book.
Still interesting.
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4.0 out of 5 stars Timely great book!! June 14 2013
Format:Hardcover|Verified Purchase
I purchased this book after seeing a short Utube clip by the author summarizing its contents. With health care costs skyrocketing, the contents of this book offers some suggestions of how to reduce our health care costs and to improve the quality and timeliness of our care PROVIDED we Consumers take the initiative and the Medical Profession cooperates!!
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5.0 out of 5 stars Todays Doctor March 13 2013
By Cliffy
Format:Hardcover|Verified Purchase
This book is a must read, it shows us how far we have come in medicine and what to look forward to.
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Amazon.com: 4.3 out of 5 stars  148 reviews
126 of 136 people found the following review helpful
4.0 out of 5 stars Informative, but doesn't live up to the potential Feb. 28 2012
By Sreeram Ramakrishnan - Published on Amazon.com
Format:Hardcover
For a book that has pages of endorsements from key authors and influential physicians, this book fails to meet the expectations - particularly in defining remarkably new disruptive ideas. Despite an excellent set-up and problem definition, this book ends up reading like a well-organized collection of articles from magazines such as Wired.

The premise of Topol is a compelling one - the developments and the relative maturity of mobile devices, PCs, Internet, genome sequencing and social media, provides a potential inflection point in the field of medicine. In the initial chapters that borrows heavily from themes established by Clay Shirky (for example, Cognitive Surplus: How Technology Makes Consumers into Collaborators, and those similar to ones defined in Hamlet's BlackBerry: Building a Good Life in the Digital Age and The Third Screen: Marketing to Your Customers in a World Gone Mobile, Topol abstracts 4 key trends (4 C's) that are setting up the stage for the "Ds" - destructive trends. While the ideas themselves are not new, Topol condenses the ideas from various authors to clearly characterize the innovation potential in medicine. Topol also makes some astute observations on the use of guidelines and the limitations of population-based clinical trials. While this first part alone is worth the book, the rest of the book fails to live up to the excellent framing.

The disappointment mostly stems from a lack of new ideas that could do full justice to the tagline of the book - instead of offering new ideas, for the most part, Topol provides an assessment of well-cited relatively new business models (23andme, patient-like me, Hello health, Vscan, etc) - across a variety of themes in physiology, biology, anatomy, and electronic health records. Mixing anecdotes from his own experience, popular literature (science and general news magazines), and academic papers, Topol is able to provide a credible assessment of the cited business models and use them as a context to define some important questions (but often fails to fully address them).

Topol glosses over issues related to who will pay for these services once they are established - this, perhaps is an important oversight in the book - the lack of discussion on how the value captured by either the patient or provider through these technologies be converted to a sustainable business model. Topol also fails to explain how the higher level of IT infrastructure can be justified in terms of the actual health outcomes that can be attributed to those (in fact, Topol himself argues that increased access to information doesn't necessarily empower patients correctly). At times, he gets carried away describing his observations - for example, he wonders if the increasing use of supplements is a "rebellion against conventional medicine". Topol chooses to ignore analyzing other stakeholders such as pharmacies, nutritionists whose roles and business models have significant disruptive potential from the trends he outlines. While the line between "medicine" and "healthcare delivery" are blurring, a sharper focus on either would've tremendously helped a reader.

Despite these 'issues' and a general lack of provocative new ideas, Topol provides an excellent characterization of the potential of disruptive technologies. One wishes that he would have used his unique experiences and reputation to put forward provocative ideas or perhaps build on the themes by an endorser of this book - The Innovator's Prescription: A Disruptive Solution for Health Care. Despite being an informative read, this book is not very likely to inspire a reader familiar with the trends in this field and the author's reputation as a thought leader. For someone new to this field, this is a remarkably comprehensive introduction to the key trends that could impact healthcare/medicine.
79 of 87 people found the following review helpful
5.0 out of 5 stars Doctors beware! Jan. 29 2012
By Sam Santhosh - Published on Amazon.com
Format:Hardcover|Verified Purchase
Every revolution shows the incumbents in poor light - they look foolish, stubborn and indecisive. Eric Topol shows how breakthrough growth in mobile phones, wireless technologies and genomics, and their convergence is revolutionizing Medicine and Healthcare but the current 'high priests' whether it is doctors or the bureaucracy dont seem to be getting it. Nevertheless the flow seems to be irreversible as informed consumers empower themselves and push for new solutions that will provide better care, cheaper and more effective medicines, and democratize the healthcare system.

Topols' stories about the shortcomings on the current system are scary and he is very tough on the members of his profession. Other players in the ecosystem like the Pharma companies also do not escape his sharp criticism. He will not be making many friends with this book - however it will be tremendously useful to the readers in multiple ways - as an individual on how to plan for your healthcare, as a student on planning your career, as an investor or entrepreneur for understanding opportunities that would create revolutionary wealth!. For people in the healthcare profession this should be a wake up call.

I would urge all to read this book.
37 of 39 people found the following review helpful
5.0 out of 5 stars Health Care's Schumpeter Moment March 18 2012
By Kathleen Scarbrough - Published on Amazon.com
Format:Kindle Edition|Verified Purchase
Dr. Eric Topol's book is an excellent review of what the promise of technology holds for the US Healthcare system. His background as a geneticist and a cardiologist as well as a highly regarded research scientist informs this book with the promise of the future, and it is the near future at that. Not something decades away. The advent of the empowered patient (by technology as close as their cell phone) extends the opportunity and methodology for significant reductions in the cost of health care for us all---without a reduction in quality. For instance, cell phones with a "lab on a chip" enabling individuals to substantially reduce the cost and compliance of monitoring one's blood work for glucose, cholesterol, etc. while empowering the patient to be more aware and in control.

His review of genetics was a little dense, but as readers we must all bear in mind how difficult it is to condense such a complex subject into a chapter of one book providing enough information for the lay person to become excited about the possibilities in front of us without speaking totally over our heads. The promise of pharmacogenomics is here today. Enabling an oncologist to test a cancer tumor for genetic markers that indicate which of several chemotherapy drugs would be most efficacious for a particular patient. The "wrinkle" in the system is that insurance company awareness and subsequent payments are running behind the speeding train of "Star Trek" medicine. I do believe we will as a society work this out.

As a health care professional, I highly recommend this book for nurses, physicians, administrators as well as interested lay people. There are so many cost pressures coming with health care reform, it is easy to get caught up in thinking that quality of care is doomed to decline. This book opened my eyes to the possibilities in front of us today and many hopes in front of us within the next 5 years. It truly lifted my spirits to read it.

Thank you Dr. Topol.
19 of 20 people found the following review helpful
5.0 out of 5 stars Awesome Book On the Future Overhaul of Medicine March 7 2012
By Doc Rog - Published on Amazon.com
Format:Hardcover|Verified Purchase
Dr. Eric Topol is one of the most famous and accomplished Cardiologists in the world. He does an amazing job at simplifying the complex field of genetics to give us insight on the future of medicine. He stresses the point that only a small percentage of patients may derive significant measurable benefit from a medicine over a 5 to 10 year period. It is likely one's genetic makeup that determines whether a medicine may led to benefit or harm. This book should be required reading for all of us in the field of medicine. It is clearly written with great stories. What a fabulous book by a legendary scientist.
92 of 115 people found the following review helpful
2.0 out of 5 stars Dry Literature Review - Not a Narrative Jan. 14 2012
By D. W. Miller, Jr. - Published on Amazon.com
Format:Kindle Edition|Verified Purchase
This book was highly recommended to me by a physician colleague and I eagerly downloaded it to my Kindle and began reading. I was greatly disappointed.

With all due respect to the author, a well-known, highly-respected, and apparently very well-connected physician, this book comes across as a dry, comprehensive academic literature review with almost every sentence referenced and descriptive of some study or article from a short list of leading periodicals/newspapers/magazines. It seems the author just did a literature search on a set of topics, summarized each reference in a sentence or two, organized the snippets, and then strung them together into a book. Apparently, the author only reads The Economist, The Wall Street Journal, The New York Times, Science, and Wired. Without all the descriptive bloat specifying each study, where it came from, where it was published, how many participants, ad nauseum, the book would be half as long (and a third of the book is notes/references).

Additionally, where there is narrative in the book, most of the time it had very little to do with the title of the book. The explanation of genetic decoding went on and on and was barely comprehensible with all the specific jargon of the science. The author wanted to illuminate readers about important topics (e.g. treating a population rather than an individual) but it seemed off-topic with this title (and was on-topic in Your Medical Mind by Groopman which addressed that issue well).

It also seemed to me that the author promoted ventures where he played an inside role in the venture or at least was a beta-tester. At times, his description of some ventures (e.g. the hand-held cardiac ultrasound device) seemed promotional.

So, I was looking for more narrative to the point of the title, and less academic referencing and dryness as if this were a published literature review in some peer-reviewed medical journal.
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