I look forward to AI doing all the heavy lifting when it comes to the science of medicine, thereby allowing practitioners to return to the art.
Please join me on a trip into the future. It might sound a little like science fiction. Bear with me, as the future is circuitous.
The Human Genome Project was a landmark international research effort from 1990 to 2003. Following its completion, scientific inquiry shifted to the field of epigenetics. You could carry, for example, the gene for disease X, but the condition is not inevitable. Certain epigenetic triggers may need to be initiated first.
While scientific knowledge is iterative, currently there is a consensus that allostatic load in early life, plus the complex array of hormonal and other whole-body neuro-signalling, are critically involved in epigenetic trigger discharge. Hence the attention on the First 2000 Days.
One way of scoring allostatic load is the Adverse Childhood Experience (ACE) Score. While a high score does not absolutely predict mind-body “disease”, it significantly increases the odds. The ACE score sits between 0 and 10. A heightened burden of disease is set at scores of four or more. I work with patients who have scores of 8 to 10.
I am an addiction medicine specialist, working in the public sector. For my cohort, drugs were the solution, until they weren’t. Addiction for them is a secondary symptom of a more primary condition, early childhood trauma. Ironically, a traumatised child will get our sympathy, while that same child as an adult will provoke societal malevolence. Therein lies the paradox of stigma and the power of social network theory.
In the future, I predict that the Diagnostic Statistical Manual (DSM) and the International Classification of Disease (ICD) codes for mental, or brain conditions will evolve from their current categorical nature. Categorical coding is suited for a stocktaking, inventory or billing purpose. However, it provides little to enhance a deeper understanding of complex mental and behavioural disorder aetiology.
We are now seeing evidence of a gut-liver-brain-neuroendocrine axis. Substance use disorder, for instance, could just as well be named labelled a gut-liver-brain-neuroendocrine axis disorder. This does, of course, ignore the social network and larger environmental predisposing, precipitating and perpetuation factors. At any rate, the consequences of our new paradigm are that we can no longer differentiate between mind and body diseases.
If you accept that modern medicine began in the early 1900s, then the first 100 years were devoted to improving the medical response to acute emergencies.
In the future we will see a move away from acute “magic bullet cures” towards chronic disease management. This will require disinvesting in services at the bottom of the cliff and investing in services at the top of the cliff. In total the return on investment in illness care prohibits further outlay on a proverbial black hole.
We will still need to triage and initiate acute episodic “ambulance” treatments, but they have tended to consume all the oxygen in the room.
Only foolish doctors think they can save a life. At best we can prolong life. We aim to see how much difference we can make in the lives of others. At the micro level we can do this by including psycho-education in our care packages, at the macro level through advocacy.
The last 40 years have seen little shift in population health literacy rates. Around 60% of adult Australians have low health literacy, meaning they struggle to access, understand, appraise, and apply health information to make informed decisions about their health.
This lack of health literacy is a significant concern as it is linked to poorer health outcomes, increased hospitalisation rates, and a reduced ability for people to actively participate in their own care.
AI threatens to run rogue through the current workforce as we know it. If we do not know what the workforce needs will be, the best strategy is to retreat to an historical educational baseline. I refer to the dynamic duo of philosophy and rhetoric.
Philosophy teaches students how to think about thinking. Rhetoric teaches how to form an argument and, more importantly, how to spot a bad one. Combined they provide skills for critical thinking.
Most of our non-infectious chronic diseases are abetted by commercially motivated toxic propaganda, so sophisticated as to hoodwink the best of us.
To paraphrase Bertrand Russell, modern education was conceived more in terms of indoctrination by most schools than in terms of enlightenment. My own belief is that education must be subversive if it is to be meaningful. It should instil a desire to question and doubt. Without this the mere instruction to memorise information is empty. The attempt to enforce conventional mediocrity on the young is criminal.
The doctor-patient relationship needs to be replaced by a medical coach-person partnership. Often this will extend into addressing the underlying early allostatic load and ACE issues and navigating the propaganda swamping the environment.
I look forward to AI doing all the heavy lifting when it comes to the science of medicine, thereby allowing practitioners to return to the art of medicine by improving the patient journey and addressing the intricate human context of the tasks at hand.
The early part of the 20th century had medical science search for the quick fix. A set and forget. This has never worked in chronic illness.
The American journalist HL Mencken had this to say about quick fixes: “Every complex problem has a solution which is simple, direct, plausible – and wrong.”
I foresee a future when doctors and patients alike, cease their fixation on “magic bullet cures” and focus more on the reality of lifestyle changes and lifelong self-care with a rejection of those parts of the material commercial world that make and keep us sick.
Associate Professor Kees Nydam was at various times an emergency physician and ED director in Wollongong, Campbeltown and Bundaberg. He continues to work as a senior specialist in addiction medicine and to teach medical students attending the University of Queensland, Rural Clinical School. He is also a poet and songwriter.
