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BMJ No 7121 Volume 315 Medicine and books Saturday 6 December 1997 21st Century Miracle Medicine Alexandra Wyke Plenon, £16.33, pp 352 ISBN 0 306 45565 X Dr Wyke is well placed to embark on this exercise in predicting the future of medicine, with a doctorate in biochemistry and 15 years as healthcare correspondent with the Economist. She began her task by setting out on a whirlwind tour, mainly in the United States, to talk to those at the growing edges of both technology and the organisation of health care for their views about how medicine would be in the year 2050. She begins with the familiar litany of criticisms of medicine today - overuse of diagnostic and therapeutic interventions, halfway technologies prolonging disabled lives without curing, and iatrogenic ills from hospital infections and medical mishaps. These are associated with more healthcare staff and escalating costs, and the whole enterprise is compromised by poor communication between doctor and patient, doctor and doctor, and teacher and taught. Communication technology is rightly identified as the key to change, leading to the death of distance. Patients, with a computer-doc in their home and a personal status monitor on the wrist, will send details of their complaints and present state to a database, which will reply in minutes with diagnosis, prognosis, and recommended treatment. If drugs are needed these may be dispatched to the patient's home by courier; if investigation or surgery are needed a mobile unit will soon park in the drive, with medimechanics and robo-docs to do what is needed. Much surgery will be minimally invasive or non-invasive, by means of ultrasound, microwaves, or lasers. But the robo-doc will do much of the traditional surgery that is still needed - such as hip replacements. Surgeons might find a role in directing such interventions from a distance, using virtual reality technology to improve their visualisation of the operative field. Computerised data processing will also record all interventions and outcomes and thereby provide a continually updated audit as a basis for assessing the efficacy of alternative treatments and for adjusting the algorithms for investigation and treatment. Patients will have direct access to data about alternative investigations, drugs, and interventions and will make their own choices among these - although only items of proved efficacy may be authorised. As befits someone from the Economist, Wyke considers the business side of this new medicine. She predicts huge profits from a small number of large corporations, which will wield enormous influence over the provision of health care. She has nothing to say about the consequences of these technological developments for the masses of sick people in third world countries, whose needs are quite different and for whom almost all that is mentioned here is irrelevant. Gene therapy and genetic screening are expected to reduce cases of cancer, cardiovascular disease, and some neurological diseases. Wyke is optimistic that newly emerging infections will be controlled much sooner than happens at present. Her conclusion is that, with less disease and more efficient health care, hospitals reduced to emergency stations for accident victims, and expensive professional staff almost an endangered species, the cost of health care would be greatly reduced (reminiscent of predictions made at the inception of the NHS that, with better health care, costs would be less). She boldly predicts the distribution of causes of death in 2050, when the average life expectancy would be about 100 years. By the end of chapter 11, the impression is that doctors are a spent force as decision makers - giving way to consumers and healthcare managers - and as technicians - replaced by automated technologies. Then comes the chapter "Doctors' dilemmas." Wyke asserts that tender loving care is already being marginalised by present day medicine as a result of accepting the mechanistic, reductionist approach to medicine - find out how the body machine is malfunctioning and fix it. Indeed, all the predicted technological developments are based on this premise, but this chapter acknowledges that mental and social factors which influence sickness behaviour are important, as evidenced by the popularity of holistic approaches and alternative medicine today. So Wyke sees a role for the doctor in providing social healing and advising patients in accessing and interpreting the myriad medical data available to them. But, having generously allowed doctors this limited role, she goes on to say that much of this could be done by nurses, who are often more acceptable to patients and are always cheaper for managers to employ. The final chapter, "Against change," recognises that medical technology may not advance quite as smoothly or rapidly as her optimistic early chapters predict. Apart from patent disputes within the healthcare industry, there are the public's fears about the confidentiality of their computerised personal data, and the fear of science and technology in general and of genetic manipulation in particular. And will people use the data and technologies wisely, or will they overuse interventions for disease and underuse preventive measures, as doctors are accused of doing today? But even if only some of Wyke's predictions prove correct, it is important to consider them all. They provoke thought and could lead us to adjust priorities now as some insurance against the future. Bryan Jennett neurosurgeon, Institute of Neurological Sciences, Glasgow Rating: *** Home | Current issue | Past issues | Classified ads | Career Focus | Feedback Collections | About this site | About the BMJ | BMA | Medline