Whither medicine?

In his introduction to The Cambridge History of Medicine, Roy Porter outlined the great paradox of 20th century medicine: better health and longer life have been accompanied by ever greater medical anxieties. Medicine, he argued, has become a victim of its own success. It has conquered many of the gravest diseases, but power and effectiveness have brought unrealistic expectations, critical scrutiny, distrust, and loss of direction. The second half of the 20th century in particular brought us, among other things, penicillin, the contraceptive pill, steroids, transplant surgery, and, in the United Kingdom, the creation of the NHS, perhaps the most important manifestation of medicine as a social utility. Writing in the BMJ in 1949, on the brink of this unprecedented progress, the distinguished physician Lord Horder exuded the uncomplicated confidence of the time. “Whither medicine?” he asked. “Why, whither else but straight ahead.” As Porter says, “Today, who even knows where ‘straight ahead’ lies?”

The BMJ has been called the mirror of medicine, so you would expect it to reflect this disquiet and doubt. In this week's journal, Jack Fairhead and Peter Rothwell find that the people most at risk of transient ischaemic attacks and minor strokes—patients more than 80 years old—are just as likely to benefit from treatment as younger patients but are far less likely to be investigated and treated (p 525). In an accompanying editorial, John Young says that ageism will always prosper when resources are inadequate for the target population (p 508). A Cecile Janssens tries to dampen unrealistic expectations that there will soon be a genetic test for type 2 diabetes and urges us instead to focus on applying what we already know to prevent diabetes and its complications (p 509).

Lambert Schuwirth and Cees van der Vleuten ask how we can make medical education more effective in the face of shorter working hours and patients' understandable unwillingness to serve as learning objects (p 544). And Andrea Akkad and colleagues find that one of the pillars of patients' autonomy, written consent for treatment, is seen by most patients as a means of allowing doctors to take control (p 528).

But none of these complexities should blind us to the astounding successes of modern medicine—what Porter calls “the dependable ability to vanquish life threatening disease on a vast scale.” Medical advances may in fact account for more than 75% of improved human survival (see Richard Lehman's journals blog on bmj.com). To coincide with next January's relaunch of the BMJ, with new content and a new design, we want to celebrate what medicine and health care have achieved since the BMJ was founded in 1840. As Trevor Jackson explains (see Contents, 10.1136/bmj.38965.474363.F7), we are asking BMJ readers to nominate the medical, scientific, and social innovations that have done most to benefit mankind and from which we have most to learn for the future.

Roy Porter himself died young by today's standards and before the beginning of the new millennium. But he left us some advice: “The task facing medicine in the 21st century will be to redefine its limits even as it extends its capacities.”