A better future for healthcare – series

This November (2020) the College of Medicine is 10 years old. We intend to use this as an opportunity for renewal. For some time it has become clear that we need a new medical perspective. Not only to withstand the ever-increasing incidence of long-term disease but also to overcome problems created by our current methods such as increasing antibiotic resistance and addiction to opioids. Covid has further shaken medical complacency.

Consequently, we have brought together some of the best talents and leaders within the College of Medicine to write 15 short chapters on how medicine needs to change in all its various areas from addressing inequalities and developing local communities to improving the lifestyle of our young and the elderly. The five extracts that follow are a preview of a manifesto to be launched later this year. It will not be just another think-piece; it outlines quite specifically how the college and others will extend the reach and effectiveness of medicine over the next 10 years. The time for talking is over and we need to be bold and challenging, which is exactly what we intend to do. You can be the judge of that and this issue of JHH will give you a flavour of our revolution to come.

Michael Dixon

Chair if Council, College of Medicine

The 5 extracts including this one:

1. Reimagining a healthful environment
2. Reimagining medical research
3. Nurturing self-care
4. Reimagining practitioner wellbeing
5. Creating a fairer society and answering the challenges of Marmot

Stephen Holgate, Clinical research professor

Debbie Sharpe, Professor of Primary Health Care, Centre for Academic Primary Care, University of Bristol

Published in JHH17.3 – Beyond Covid

What are the problems we are trying to solve?

The vast majority of biomedical research has focused on treating diseases and a much smaller part on maintaining health and prevention efforts. Strangely, there is little research that has tried to look at the big picture – what makes people happy, resilient, creative, fully exploring their potential and living not only healthy, but more-thanhealthy lives. Catherine Heaney (2017), associate professor of psychology and medicine at Stanford, suggested that there are 10 domains of wellness that people most commonly mention: social connectedness, lifestyle behaviours, stress and resilience, emotional health, physical health, meaning and purpose, sense of self, finances, spirituality or religiosity and exploration and creativity. In trying to understand the biological interactions required to maintain a state of ‘wellness’, advances in systems biology and application of ’omics’ technologies has allowed comprehensive analysis of how complex biological systems are impacted by external perturbations (eg, nutrition and exercise), and are therefore gradually pushing personalised lifestyle medicine toward reality.

Clinicians and healthcare practitioners have a unique opportunity in advocating lifestyle medicine because patients see them as a reliable source of advice. Non-communicable degenerative diseases and cancer (NCDs) now drive the majority of healthcare through the provision of ‘sick care’, a system that works well for treating acute diseases or acute worsening of chronic disorders. Clinicians and patients have come to expect immediate pharmaceutical solutions for instant cure or symptom relief. Not only is this concept inappropriate in treating NCDs, it largely ignores the sub-clinical stage of disease development and lacks ability and incentive to properly address disease-promoting lifestyles, the underlying causes of NCDs. A drastically different approach to healthcare is in urgent need (Fiala et al, 2019).

What makes each individual different is not just due to genetic variation. Environmental factors, epigenetics, gene-environmental interactions, and many others together modify our nutritional requirement, metabolism, and predisposition to disease, as well as our response to drug or lifestyle intervention. Integrating these pieces of information will allow healthcare professionals to provide personalised nutrition and lifestyle recommendations that minimise side-effects and optimise efficacy. The application of systems biology to develop personalised healthcare is referred to as systems medicine.

How can we solve these problems?

The advent of high dimensional analytical tools that can simultaneously detect and identify many thousands of individual molecules is the new ’omics science in which genomics, transcriptomics, proteomics, metabolomics and microbiomics, when coupled with real-time sensor monitoring, functional imaging and computerised pathway analyses, enables a molecular network to be constructed, in which deviations from normal patterns provide new clues to complex disorders and are helping define the boundaries of wellness and illness. This systems approach to biology and medicine is now beginning to provide patients, consumers and physicians with personalised information about each individual’s unique health experience of both health and disease at the molecular, cellular and organ levels. This information will make disease care radically more cost effective by personalising care to each person’s unique biology and by treating the causes rather than the symptoms of disease. It will also provide the basis for concrete action by consumers to improve their health as they observe the impact of lifestyle decisions. Working together in digitally powered familial and affinity networks, consumers will be able to reduce the incidence of the complex chronic diseases that currently account for 75% of disease care (Bland et al, 2017)

The term P4 medicine (predictive, preventative, personalised, participatory) was coined by Leroy Hood of the Institute for Systems Biology to demonstrate such a framework to detect and prevent disease through extensive biomarker testing, close monitoring, deep statistical analysis, and patient health coaching. Hippocrates’ conception of the human body was not unlike that of system biologists today; he described it as ‘one unified organism to be considered as one coherent and integrated whole’. This framework allowed him to interpret disease in a novel way and view health and sickness as a continuum, just like P4 medicine proponents. Hippocrates wrote, ‘diseases never affect only one part of the body, they affect the health balance of all [the] body’. Consequently, he focused on interpreting present trends of each sickness and the patient’s physical and social environment to predict illness progression. In doing so, he declared, ‘the best physician is one who can prevent and predict diseases’, which bears strong parallels with 21st century P4 medicine’s emphasises on prediction and prevention (Flores et al, 2013).

With his emphasis on careful examination and deep knowledge of the patient’s past and environment, Hippocrates revolutionised medicine. He saw each person as an individual and focused on gathering as much information about each patient as possible, proclaiming ‘he who administers therapy must first know the whole man as a unique psychosomatic entity in relation to his social and natural environment’ (Pulciani et al, 2017). In these ways, he was practicing personalised medicine millennia before P4 systems biology and other highly publicised personalised medicine initiatives.

References

• Bland JS, Minich DM, Eck BM (2017) A systems medicine approach: translating emerging science into individualized wellness. Adv Med, 217, 1718957.
• Fiala C, Taher J, Diamandis EP (2019) P4 medicine or O4 medicine?
• Hippocrates Provides the Answer. J Appl Lab Med, 9(4) 108–19.
• Flores M, Glusman G, Brogaard K, Price ND, Hood L (2013) P4 medicine: how systems medicine will transform the healthcare sector and society. Per Med, 10, 565–576.
• Heaney CA, Rich T, Evered J, Winter SJ,Avery E (2017) Well-being over the life course: Changes and adaptations. Innovation in Aging, 1, suppl 1,878.
• Pulciani S, Di Lonardo A, Fagnani C, Taruscio D (2017) P4 medicine versus Hippocrates. Ann Ist Super Sanita. 53, 185–91.