Medicine in the 21st Century
As we construct our plan together for the next ten years, it is critical for us to envision the future of medicine in the 21st Century. Let me start with a couple of observations about societal changes that will impact health care. Changes in demographics make it increasingly important for aging individuals to remain functional and active in their advanced years. The data show that, in spite of chronic illnesses, disability by age group is decreasing in the U.S., but changes in our economy are requiring people of retirement age to continue working longer. Hence, keeping our human fellows in fully functional condition for nearly all of their lives will become increasingly important.
Another critical issue we have to deal with is the overwhelming cost of health care in the U.S. Fundamentally, we have to switch from a reactive health care system to a proactive health care system. Interventions must begin before chronic illnesses take root and become clinically evident; the prevention of illnesses is likely to be less costly than the reactive management of illnesses already at the point of crisis. However, for prevention to be cost-effective, it needs to be applied according to scientific evidence of best practice and careful consideration of risk and benefit. Clinical and health service research are essential to help us design evidence-based, quality improvements and strategies to prevent the onset of chronic illnesses.
The figure depicts a typical course for a chronic illness. From asymptomatic susceptibility, increasingly discoverable with genomics, to a tipping point followed by clinical manifestations, most disorders should be prevented way before the clinical phase. Effective prevention may include novel strategies such as those involving stem cells, new mechanisms to rev-up the immune system, and others, once supported as evidence based medicine, and all should be used even before the disease takes a toll on the target organ/tissue. Consequently, organ/tissue dysfunction could be delayed, which we find to be increasingly required to allow humans to remain active until late in life, sheltered from chronic illnesses.
For most chronic illnesses, it is clear that humans are born with a genetic susceptibility. Some may have susceptibility for diabetes and cardiovascular disease, some for specific forms of cancer, others for neuropsychiatric degenerative disorders, such as Alzheimer, schizophrenia and many more. Susceptibilities at birth for these disorders are mediated by gene variants. We now have the opportunity to identify susceptibility for chronic illnesses using genomic techniques, such as genotyping and sequencing, or identification of epigenetic changes, that were not available before. In the near future we will be integrating such tests into daily clinical care. Whenever susceptibility for a chronic illness is present, its development depends, at least in part, on environmental factors such as smoking, exercise, diet, and other behaviors that may either protect against, or contribute to, the development of the illness.
Typically, the chronic illness will remain clinically invisible for many years until a tipping point (figure) is reached. The timing for such a tipping point may reflect the intrinsic ability of tissue repair mechanisms to compensate for external injuries applied to the tissue/organ, and thus maintain tissue homeostasis. Growing evidence suggests that the tipping point takes place when this intrinsic repair mechanism can no longer compensate for cell and tissue injury. At that point, the tissue/organ/system starts to degrade and becomes dysfunctional.
Research is identifying markers for this transition phase from healthy to ill, and biomarkers and imaging technologies are increasingly capable of recognizing individuals who have reached the tipping point. Novel therapies, such as adult or other stem cells that can improve tissue and organ repair, could be applied at that point, or even before, when supported by clinical research. This type of intervention will increasingly become a major aspect of medicine for the 21st Century.
Once a chronic disease is established and clinically detectable, much of the involved organ has already been damaged. Current therapeutics are designed to ameliorate symptoms and stabilize disease progress with little or no opportunity for disease regression, except when drastic treatment, such as organ transplant (and perhaps selected cellular therapies) is applied. The development of novel techniques capable of stimulating repair and inducing disease regression has been limited so far, but is a research priority for the 21st Century. Hence, development of devices and drugs, new vaccines (for example, against specific cancers, or cancer-causing microorganisms), stem cell-based preventive and therapeutic strategies, novel biomarkers and imaging technologies will contribute to improving medicine of the 21st Century.
Collectively, with our science, our expertise and our compassion, we can all contribute to this true medical revolution. The advance of our informatics systems will eventually facilitate the incorporation of new diagnostic tools and intervention strategies into our medical armamentarium. I still remember how I first learned to care for a patient with a heart attack: nitrates, oxygen, morphine and bed rest. Today, we have many tools to minimize the impact of heart attacks and protect the heart of the patient, including angioplasty procedures, strong anti-platelet agents, lipid-lowering medications, beta blockers and ACE inhibitors. These changes took place in just 30 years. Where will we be in 2050? Perhaps the treatments of today will once again look obsolete.
We also need to work on improving access, maximizing the patient centricity of our culture, and making sure that we address patient needs in a compassionate and holistic fashion. In so many ways, clinical and health services research will be key also to moving medicine forward, and we must ensure as an academic health center that all patients are provided with access to the most cutting edge clinical studies. There is room for all of us to contribute to the future of medicine. I am looking forward to taking this challenge and opportunity with all of you, and making the Miller School and UHealth one of the top academic health centers in the nation.
Thank you for all you do.