Over the last year the Journal of Internal Medicine has published a series of invited articles that were chosen to reflect the hopes and problems of medical practice as it enters the new millennium. Selecting these topics was not easy, particularly in view of the present uncertainties of the medical scene and about the time-scale of the much publicized advances that may follow from the remarkable developments in the basic biological sciences, not least the Human Genome Project. In the event it was decided to offer a broad spectrum of subjects, ranging from medical education, a patient's view of the current health scene and medicine in the elderly, to the future of pharmacology and some glimpses of further refinements in high-technology practice. Finally, and as a prelude to the celebration of the announcement of the partial completion of the Human Genome Project, several articles tried to anticipate the ways in which its fruits may reach clinical practice.
Paradoxically, it is not an easy time to gaze into the looking glass and try to see into the future for the world of patient care. On the one hand, the medical sciences are about to enter the most exciting phase of their development yet; at the same time, medical practice is passing through a phase of great uncertainty, both in industrialized countries and in the developing world. None of the richer countries have got to grips with the rapidly increasing problem of their elderly populations and the spiralling costs of health care. Increasingly, their doctors are perceived as uncaring technocrats whose pastoral role seems to have been lost in the frenetic pace of modern practice and its increasingly high technology. Even the primary care sector is having difficulty giving sufficient time to the problems of its patients, many of which stem from difficulties in adapting to an increasingly complex society. and the pressures on hospital staff, stemming from our inability to control many of our common killers, together with the increasing age of their patients, not to mention their multisystem diseases, are not faring much better.
Criticisms of the profession are coming from all directions, ranging from patient dissatisfaction to the wrath of governments, which would rather lay the blame on the medical profession for its inefficiency than face the fact that health care is chronically underfunded, regardless of whether it is financed by the state or the private sector.
As we come to the end of the first year of the new millennium what is being done to try to tackle some of these problems? Most countries are in the process of reforming medical education with the objective of producing more rounded and caring doctors. Whilst these reforms differ in detail from place to place, they are all based on the general principles of early exposure of students to patients, some dilution of the basic biological sciences with social science and communication skills, a greater focus on ethics and, in an effort to broader a doctor's perception, increasing focus on the humanities. Whilst these new approaches to training doctors, particularly the emphasis on communication and ethics, are a move in the right direction, it is vital that in our enthusiasm to produce caring clinicians we do not leave them unprepared for the information explosion that will stem from the clinical fallout from the basic biological sciences which is already with us or, and even more importantly, neglect the fundamentals of clinical method and technical skills. After all, whilst we would all like our personal surgeon to be a good listener who takes a holistic approach to our problems, and undoubtedly would be reassured to hear that they play string quartets in the evenings and read themselves to sleep with Tolstoy, we might be even happier to know that they had, along the way, acquired the basic skills required to find their way round after our abdomens.
Because of the complex multisystem disorders that are becoming increasingly common in our older population we are having to review postgraduate education and reassess the vital role of the generalist in patient care, particularly of the elderly. This, together with a continued focus on sound clinical technique in medical education, is particularly important since it is unlikely that there will be a major change in the pattern of health care in the early part of this century. In the developed countries we will have to learn how to apply the few certainties that have come from epidemiology for the prevention of disease.
But the management of established disease will continue to depend on traditional clinical methods backed up by further refinements in our already sophisticated technology. As the poorer countries go through demographic transition, and childhood mortality fails, their patterns of diseases will start to resemble those of the west.
The first year of the new millennium has been particularly exciting for the field of vaccine development, with hints of breakthroughs in AIDS, malaria and tuberculosis. But we now know enough about the biology of micro-organisms to realize that their genetic cunning will ensure that they are always with us; they were here when we arrived and it likely that they will still be here when homosapiens departs. The same principles applies to many diseases, for example cancer. The remarkable progress that has been made towards an understanding of the cellular basis for cancer has shown us, particularly in the case of multigene-expression arrays of cancer cells, that it is an extraordinarily heterogeneous disease and that many apparently identical forms can result from the abnormal function of completely different sets of oncogenes. Granted, there is major scope for its prevention by the control of environment carcinogens, but because it also reflects the results of damage to our DNA as part of the arcane mechanisms of ageing is unlikely that we shall ever be able to eradicate it. The same applies to many of the diseases of middle and old age.
Given this uncertain scenario, what can we expect of the post-genome period? We will undoubtedly learn more about the pathophysiological mechanisms of common disease and it would be very surprising if this does not lead to completely new approaches to their control and management. Indeed, over the last year remarkable information has been obtained about the precision of drug action at the molecular level in a family of new drugs designed to control a form of chronic leukaemia. Similarly, as we explore the genome of micro-organisms this information will almost certainly provide us with new forms of chemotherapy. But because of the multiple routes towards cancer, therapy may end up having to be tailor-made for each individual neoplasm. Most of the common diseases of middle life and old age may require a similar and potentially extremely expensive approach. But all this will take a long time and there will be no explosive, overnight changes in clinical practice. and the reaction of our patients to their diseases, including their increased expectations of their doctors, will not alter. For these reasons we will rely, for the foreseeable future, on the traditional skills of communication and good clinical method, hopefully combined with a return to kindness and understanding that used to be the hallmark of our profession.
Clearly, although we are undoubtedly embarking on the most exciting period for the development of the medical sciences and have the potential to improve the health of our populations, we must not hope for too much too quickly. But if we are to make best use of the opportunities for improved health that will undoubtedly present themselves, and try to regain the virtues of a caring profession, we will have to engage in a major programme of education of governments, international health agencies and others on whom we rely to support the provision of health care. The enormous promise for the development of vaccines and agents to treat the major infectious killers of the developing world will all come to nothing if the international health community is unable to pay for them to be applied in parts of the world where there is still dire poverty; the richer countries will have to take a completely different approach to the politics of health.
Unfortunately, and not always for the right reasons, health has become a major political issue which in many countries has led to short-term ad hoc decision-making with no long-term planning and appropriate pilot studies for new developments. Politicians should be involved with major strategic issues such as what proportion of a country's GIDP is spent on health. After that its planning should be dissociated from the world of politics so that a long-term view can be taken; massive overnight reforms of health care designed to gain votes for the next election should become a thing of the past, and health planning should be left to independent groups of experts with a major input from consumers. Similarly, completely independent bodies will have to deal with the increasingly complex ethical issues that are arising, not just from the advances in biology but from the even more pressing problems of rationing and prioritizing the delivery of care to an increasingly aged population. Above all, we must convey the message to governments and health economists that clinical care cannot be organized in the same way as a large company or a supermarket, and that whatever advances are made towards the prevention or management of disease no one patient's reaction to illness is the same. Above all, good clinical practice has to be based on adequate time to talk to sick people. It is this, perhaps more than anything else, that has been lost in the frenetic supermarket of the modern medical scene