Editorial
A Glimpse of the Next 100 Years in Medicine
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- Over the past year, the Journal has commemorated 200 years of publication and the astonishing progress made since 1812 in the science and practice of medicine. Thanks to digital technology, our anniversary celebration has had a wide reach, with more than 1 million visits to the NEJM200.NEJM.org site; many viewers of our documentary video, Getting Better; and large numbers of viewers of our simulcast symposium, Dialogues in Medicine. As the Journal's 200th year comes to a close, we want to think about the changes and challenges that medicine faces in the decades ahead. Although it is foolish to attempt specific predictions about the future, it would be unwise not to think about the emerging trends, new opportunities, and the principles that should guide the medicine of the future. In the decades ahead, the pace of biomedical discovery will accelerate. The state of an individual person will be characterized with increasing precision from the molecular level to the genomic level to the organ level and by interactions with medications, nutrients, the microbiome, therapeutic devices, and the environment. This precision medicine1 will become possible because of huge data sets on large populations, with millions of characterizations of each person. Study populations will grow to millions, which will allow observational studies with novel statistical methods that will allow discovery of useful, reproducible patterns and relationships from these data. This will be possible because virtually all the data will be in an advanced infrastructure of electronic health records (EHRs) that includes input from physiological monitoring, which is already starting to become part of the management of chronic diseases and of guidelines for prevention and fitness. Therapeutic and monitoring instruments will continue to become smaller, smarter, more interactive, and more connected to the health information infrastructure. However, the quantum leaps will come not from the devices but from inferences drawn from the data. The size and complexity of this multidimensional characterization of patients will lead to far more complex diagnostic and prognostic categories than are currently in use. The multivariate descriptors of large populations will allow stratification of a kind seen only in the most recent genomically informed clinical trials.2 Massive data crunching will yield analytic or algorithmic formulas that will be useful for clinical purposes even though they defy easy summary in a language most of us can understand. Complex but empirically validated algorithms will be embedded in EHR systems as decision support tools to assist in everyday patient care. Those management algorithms will evolve and be modified continuously in accordance with inputs from ongoing clinical observations and from new research. Clinical decision support algorithms will be derived entirely from data, not expert opinion, market incentives, or committee consensus. The huge amount of data available will make it possible to draw inferences from observations that will not be encumbered by unknown confounding. Both patients and payers will demand increased transparency, particularly for new therapies that will have to be monitored in ongoing studies of comparative efficacy. This will increase the pressure on regulatory authorities for greater plasticity that will allow them to adapt rapidly, accurately, and decisively to the evolving understanding of the merits and risks of different therapies. Scientists, physicians, and the public will demand that all the primary data be made public, along with the analytical tools necessary to reanalyze, test, refine, and build on them. Data security will have to evolve and thereby win the public's trust with new techniques that will do what now seems impossible: guarantee protection of privacy while providing detailed information about each person. Societies will come to accept that comprehensive knowledge of disease, prevention, and effective treatment is an essential public good. Biomedical research, data technologies, and clinical care all require resources, but the era of shifting more and more economic resources toward health care is going to end. The medicine of the future will focus on more efficient use of resources to prevent disease, with the goal of delivering what provides the best value for the patient who needs treatment. The future of medicine also depends on reducing the enormous disparities in health, particularly those between the richest and the poorest countries of the world. A basic standard of sound medical care will become an expectation of every society. Research-rich countries may come to see that achieving basic health care throughout the world is a strategy to promote stability and peace. The increasing power of information and communication technologies can help find ways to improve global health. However, that goal also requires the educational and economic development that are essential for societies to achieve a reasonable standard of health. The moral mandate here only becomes stronger as clinical progress continues to accelerate in developed societies. The high-technology, information-rich medicine of the future will provide powerful and useful tools for clinical medicine. The medicine of the future will not, of course, solve all problems, and it cannot prevent violent or self-destructive human behaviors. Patients will continue to rely on physicians and the medical community for the guidance, support, and help that only a skilled and caring heath professional can deliver. The medical community must provide direction to ensure that powerful new technologies are used to benefit the health of all. As advances in science and technology continue to bring disruptive changes, the Journal must continue to evolve creatively in order to continue in its mission of inspiring discovery and advancing care. As we head into this medicine of the future, the Journal should remain true to the principles that were set down by its founding physicians two centuries ago: “The Journal will always be open to the accurate observer of nature, the useful experimenter, and the rational therapist.”3Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.
Source Information
From Boston Children's Hospital and Harvard Medical School — both in Boston (I.S.K.).
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