- Email: [email protected]
The science (and art) of medicine
Comment
Academy of Medical Sciences
The science (and art) of medicine
Prof Sir John Tooke Published Online February 25, 2016
6
The 19th century saw the move of medical education into the university environment in the UK so that the advances in science, and pathology in particular, could begin to inform clinical practice. Since World War 2 there has been a burgeoning increase in scientific understanding, more recently informed by genomics and sophisticated phenotyping technologies, including modern structural and functional imaging. These capabilities will be amplified further if full advantage is taken of the opportunities brought by the information revolution, which has been named the fifth revolution in human existence. The ability to interrogate large and diverse data sets will provide unprecedented insights into human biology and the molecular pathology of disease, laying the foundations for greater precision in medical diagnosis and treatment. This will give practitioners the opportunity to intervene in disease processes even before symptoms become manifest. All this potential makes the 21st century genuinely the most exciting time to engage in clinical science, a challenging but deeply rewarding career path that the Academy of Medical Science’s Spring Meeting for Clinician Scientists in Training seeks to support. But those same developments—the speed of scientific advance, the attendant clamour for faster introduction of medical innovations to address unmet clinical need, and the concerns regarding personal data security— expose other issues that need addressing in parallel if society is to take full advantage of the potential of modern science. There have been those who have taken a sombre view of this challenge. Roy Porter,1 the late celebrated social historian, argued at the end of his treatise on the history of medicine and medical science, that society’s expectations could not be fulfilled and that medicine would need to redefine its limits at the very point its technological capabilities reached unprecedented heights. Others have argued that the democratisation of knowledge, courtesy of the internet and social media, will lead to the end of professions as we know them (including medicine).2 Professions, it is argued, sequester their specialist knowledge for personal gain, a protectionism that will be destroyed by information technology and wide access to specialist knowledge.
What is indisputable is that there is an increasing expression of concern regarding the acceptability or otherwise of medical advance, the nature of the evidence that underpins it, how it is received and interpreted by society, and how personal data are utilised. Over the past year or so we have seen passionately held views expressed in the public domain on several health topics. The use of preventive agents such as statins was received with accusations of overmedicating society, other strong views were expressed towards mitochondrial transfer techniques and gene editing, and the clumsy attempted introduction of the care.data programme, to name just a few examples. The Academy of Medical Sciences has argued that pushing medical innovation without a profound appreciation of the receptivity or otherwise of society to such advances will prevent them from realising their full potential. The UK Government’s Accelerated Access Review is a worthy attempt to redefine the medical innovation pathway and the regulatory processes that control it to speed the introduction of medical innovations. The analogy of a “lit runway” has been used to allow innovation to take off. To stretch the analogy, without a lit landing zone (a receptive society), attempts to push medical innovation may well be frustrated. The Accelerated Access Review recognises this as evidenced by the primacy it gives to putting the patient centre stage in its interim report.3 To consider these issues the Academy held a workshop in the summer of 2015 to explore the need for a new social contract or compact between medicine and society.4 At the workshop it was agreed that much hinged on perceptions of both risk and value at the level of the individual (citizen, patient, and professional), system (eg, the National Health Service), and society (eg, statutory and regulatory issues). Risk, and values as they relate to medicine, were key themes in the Government’s Chief Scientific Adviser’s Harveian oration delivered in October, 2015.5 In view of the contemporary importance of these issues, the Academy of Medical Sciences has initiated a major body of work exploring how society uses evidence to judge the risks and benefits of medicines. The work will involve three major elements: the relative www.thelancet.com
Comment
value and limits of different forms of evidence; how conflicts of interest colour the acceptance of evidence and how such conflicts should be handled; and deep public dialogue to understand society’s views—the pull factors that largely determine what evidence is well received and hence what innovations are adopted and diffused. These are all issues the modern clinician scientist cannot ignore, especially if we are to move to an era of precision medicine with the potential for pre-emptive approaches long before disease is clinically apparent. To many the term personalised medicine relates to the uniqueness of an individual’s genetic code. Taking account of a patient’s or citizen’s health-beliefs and attitudes is the non-genomic side of personalised medicine, and helps us to reframe that rather vague term, the art of medicine. It also suggests that however powerful computerised diagnosis decision support tools becomes, synthesis of the objective and the subjective viewpoint may well demand a researchaware human doctor to interpret. The clinician
scientist of tomorrow is likely to be in the vanguard of such a philosophy, combining the science and art of medicine with the conduct of genuinely shared decision making to take medical practice to new heights. John Tooke Academy of Medical Sciences, London W1B 1QH, UK; and University College London, London, UK [email protected] Prof Sir John Tooke is Co-Chair of the Centre for the Advancement of Sustainable Medical Innovation, UK. 1 2 3
4 5
Porter R. The greatest benefit to mankind: a medical history of humanity from antiquity to the present. London: Harper Collins, 1999. Susskind R, Susskind D. The future of the professions. Oxford: Oxford University Press, 2015. Accelerated Access Review: interim report, 2015. https://www.gov.uk/ government/publications/accelerated-access-review-interim-report (accessed Jan 20, 2016). Academy of Medical Sciences. Exploring a new social contract for medical evidence. London: Academy of Medical Sciences, 2015. Medicine science and values – with hindsight and foresight: speech by Sir Mark Walport at the Royal College of Physicians’ Harveian Oration dinner. London: Royal College of Physicians, 2015. https://www.gov.uk/ government/speeches/medicine-science-and-values-with-hindsight-andforesight (accessed Oct 27, 2015).
In late 2014, the Academy of Medical Sciences established a new working group, comprising members drawn from many disciplines, to explore the health challenges that the UK population might face in 2040, the diverse factors driving these challenges, and the contribution that research might make in tackling them. As we near the end of this project, which was also accompanied by a programme of public dialogue, the Spring Meeting provides an excellent opportunity to reflect on the insights gained and the important role that early career researchers will have in supporting a better, fairer future for the health of the public by 2040. The world is changing, perhaps more rapidly than ever before. The changes that we will face over the next 25 years—be they technological, demographic, social, political, environmental, or economic—will inevitably present both challenges and opportunities for population health. Increasingly, we recognise global drivers of our future health, including climate and environmental change. We recognise, for example, the importance of a healthy start in life for future outcomes; the many factors influencing obesity and mental public www.thelancet.com
health; the complexity of achieving improved healthy lifespan in an ageing population; and the growing threats of antimicrobial resistance. Encompassing all these we must determinedly address the urgent need to reduce health inequalities. Many of the drivers of our future health lie upstream from individual interventions for lifestyle change. They include policies across government, legislative and fiscal interventions, the role of industry, and our ability to harness technological change to improve the health of the public. Many actors will be involved in steering our future course. The research community has an important role in shaping this trajectory by generating the evidence needed to support informed decision making across all of the realms potentially impacting the health of the public. To do this effectively, our approach will need to evolve in a number of ways. We, as researchers, need to trigger a paradigm shift in how public health is viewed as a discipline. Many now recognise the need to embrace a future for health of the public research, which involves a much wider range of stakeholders, disciplines, and social and
Academy of Medical Sciences
Health of the public in 2040
Dame Anne Johnson Published Online February 25, 2016
7
Academy of Medical Sciences
The science (and art) of medicine
Prof Sir John Tooke Published Online February 25, 2016
6
The 19th century saw the move of medical education into the university environment in the UK so that the advances in science, and pathology in particular, could begin to inform clinical practice. Since World War 2 there has been a burgeoning increase in scientific understanding, more recently informed by genomics and sophisticated phenotyping technologies, including modern structural and functional imaging. These capabilities will be amplified further if full advantage is taken of the opportunities brought by the information revolution, which has been named the fifth revolution in human existence. The ability to interrogate large and diverse data sets will provide unprecedented insights into human biology and the molecular pathology of disease, laying the foundations for greater precision in medical diagnosis and treatment. This will give practitioners the opportunity to intervene in disease processes even before symptoms become manifest. All this potential makes the 21st century genuinely the most exciting time to engage in clinical science, a challenging but deeply rewarding career path that the Academy of Medical Science’s Spring Meeting for Clinician Scientists in Training seeks to support. But those same developments—the speed of scientific advance, the attendant clamour for faster introduction of medical innovations to address unmet clinical need, and the concerns regarding personal data security— expose other issues that need addressing in parallel if society is to take full advantage of the potential of modern science. There have been those who have taken a sombre view of this challenge. Roy Porter,1 the late celebrated social historian, argued at the end of his treatise on the history of medicine and medical science, that society’s expectations could not be fulfilled and that medicine would need to redefine its limits at the very point its technological capabilities reached unprecedented heights. Others have argued that the democratisation of knowledge, courtesy of the internet and social media, will lead to the end of professions as we know them (including medicine).2 Professions, it is argued, sequester their specialist knowledge for personal gain, a protectionism that will be destroyed by information technology and wide access to specialist knowledge.
What is indisputable is that there is an increasing expression of concern regarding the acceptability or otherwise of medical advance, the nature of the evidence that underpins it, how it is received and interpreted by society, and how personal data are utilised. Over the past year or so we have seen passionately held views expressed in the public domain on several health topics. The use of preventive agents such as statins was received with accusations of overmedicating society, other strong views were expressed towards mitochondrial transfer techniques and gene editing, and the clumsy attempted introduction of the care.data programme, to name just a few examples. The Academy of Medical Sciences has argued that pushing medical innovation without a profound appreciation of the receptivity or otherwise of society to such advances will prevent them from realising their full potential. The UK Government’s Accelerated Access Review is a worthy attempt to redefine the medical innovation pathway and the regulatory processes that control it to speed the introduction of medical innovations. The analogy of a “lit runway” has been used to allow innovation to take off. To stretch the analogy, without a lit landing zone (a receptive society), attempts to push medical innovation may well be frustrated. The Accelerated Access Review recognises this as evidenced by the primacy it gives to putting the patient centre stage in its interim report.3 To consider these issues the Academy held a workshop in the summer of 2015 to explore the need for a new social contract or compact between medicine and society.4 At the workshop it was agreed that much hinged on perceptions of both risk and value at the level of the individual (citizen, patient, and professional), system (eg, the National Health Service), and society (eg, statutory and regulatory issues). Risk, and values as they relate to medicine, were key themes in the Government’s Chief Scientific Adviser’s Harveian oration delivered in October, 2015.5 In view of the contemporary importance of these issues, the Academy of Medical Sciences has initiated a major body of work exploring how society uses evidence to judge the risks and benefits of medicines. The work will involve three major elements: the relative www.thelancet.com
Comment
value and limits of different forms of evidence; how conflicts of interest colour the acceptance of evidence and how such conflicts should be handled; and deep public dialogue to understand society’s views—the pull factors that largely determine what evidence is well received and hence what innovations are adopted and diffused. These are all issues the modern clinician scientist cannot ignore, especially if we are to move to an era of precision medicine with the potential for pre-emptive approaches long before disease is clinically apparent. To many the term personalised medicine relates to the uniqueness of an individual’s genetic code. Taking account of a patient’s or citizen’s health-beliefs and attitudes is the non-genomic side of personalised medicine, and helps us to reframe that rather vague term, the art of medicine. It also suggests that however powerful computerised diagnosis decision support tools becomes, synthesis of the objective and the subjective viewpoint may well demand a researchaware human doctor to interpret. The clinician
scientist of tomorrow is likely to be in the vanguard of such a philosophy, combining the science and art of medicine with the conduct of genuinely shared decision making to take medical practice to new heights. John Tooke Academy of Medical Sciences, London W1B 1QH, UK; and University College London, London, UK [email protected] Prof Sir John Tooke is Co-Chair of the Centre for the Advancement of Sustainable Medical Innovation, UK. 1 2 3
4 5
Porter R. The greatest benefit to mankind: a medical history of humanity from antiquity to the present. London: Harper Collins, 1999. Susskind R, Susskind D. The future of the professions. Oxford: Oxford University Press, 2015. Accelerated Access Review: interim report, 2015. https://www.gov.uk/ government/publications/accelerated-access-review-interim-report (accessed Jan 20, 2016). Academy of Medical Sciences. Exploring a new social contract for medical evidence. London: Academy of Medical Sciences, 2015. Medicine science and values – with hindsight and foresight: speech by Sir Mark Walport at the Royal College of Physicians’ Harveian Oration dinner. London: Royal College of Physicians, 2015. https://www.gov.uk/ government/speeches/medicine-science-and-values-with-hindsight-andforesight (accessed Oct 27, 2015).
In late 2014, the Academy of Medical Sciences established a new working group, comprising members drawn from many disciplines, to explore the health challenges that the UK population might face in 2040, the diverse factors driving these challenges, and the contribution that research might make in tackling them. As we near the end of this project, which was also accompanied by a programme of public dialogue, the Spring Meeting provides an excellent opportunity to reflect on the insights gained and the important role that early career researchers will have in supporting a better, fairer future for the health of the public by 2040. The world is changing, perhaps more rapidly than ever before. The changes that we will face over the next 25 years—be they technological, demographic, social, political, environmental, or economic—will inevitably present both challenges and opportunities for population health. Increasingly, we recognise global drivers of our future health, including climate and environmental change. We recognise, for example, the importance of a healthy start in life for future outcomes; the many factors influencing obesity and mental public www.thelancet.com
health; the complexity of achieving improved healthy lifespan in an ageing population; and the growing threats of antimicrobial resistance. Encompassing all these we must determinedly address the urgent need to reduce health inequalities. Many of the drivers of our future health lie upstream from individual interventions for lifestyle change. They include policies across government, legislative and fiscal interventions, the role of industry, and our ability to harness technological change to improve the health of the public. Many actors will be involved in steering our future course. The research community has an important role in shaping this trajectory by generating the evidence needed to support informed decision making across all of the realms potentially impacting the health of the public. To do this effectively, our approach will need to evolve in a number of ways. We, as researchers, need to trigger a paradigm shift in how public health is viewed as a discipline. Many now recognise the need to embrace a future for health of the public research, which involves a much wider range of stakeholders, disciplines, and social and
Academy of Medical Sciences
Health of the public in 2040
Dame Anne Johnson Published Online February 25, 2016
7