Chapter
159
Quo Vadis Medicine… The Road
Ahead for Physicians
E Prabhu
A SHORT HISTORY OF MEDICINE
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2000 BC: Here, eat this root.
1000 BC: That root is heathen, say this prayer.
1850 AD: That prayer is superstition, drink this potion.
1940 AD: That potion is snake oil, swallow this pill.
1985 AD: That pill is ineffective, take this injection.
2000 AD: That injection is painful, inspire this gas.
2020 AD: That gas is toxic, here, eat this root.
~ Author Unknown
“Sareere Jarjareebhute Vyaadhigraste Kalevare; Aushadam Jahnavi
Toyam Vaidyo Narayano Harih.”
“When the body is in the grip of disease and old age, Ganga Water is
the medicine and Lord Narayana is the physician.”
~ Puranas
EXECUTIVE SUMMARY
The practice of medicine in India is built on time-tested principles
and ethics. There is a decreased inclination toward basic medical
research all along among all physicians although they are clinically
strong. Newer developments are happening at a very rapid pace
in the field of medicine and biology. Therefore, the society looks
upon the leadership support of the physicians for their well-being.
Corporatization of medicare is yet to have a significant impact on
the practice of clinical medicine. The road ahead is smooth and yet
challenging for all physicians.
order in several parts of our country. However, the clinical skills of
the physicians are challenged vigorously by the rapidly developing
technology in all segments of life sciences. The social structures,
economic goals and ethical values of the world are also shifting these
days. Computers and Internet have fully thrown open the world of
medical knowledge to everyone.
Physicians, as a consequence, have developed a vision of the
overall game plan in the field of biological sciences and are assuming
leadership roles. Perhaps, this attitude is also due to their prolonged
and rigorous training in the art of healing as well as their ardent
commitment to their patients and the society. Basic scientists,
technocrats, administrators, sociologists, investment bankers,
economists, legal experts and philosophers—for every one in the
society are keen to become a principal stakeholder in the field of
health care. Therefore, medicine would still continue to attract the
best of talents in our society.2
WHAT MAKES PHYSICIANS SPECIAL?
Physicians are trained to remain calm, keep their priorities straight
and not get distracted by the surrounding environment. They also
develop an inherent ability to learn, understand, integrate a large
volume of information and connect facts together to derive logical
conclusions. Many of them are mentally and emotionally tough and
are capable of enduring prolonged working hours under difficult
circumstances, often with no support. They are also team players
with a natural compassion and empathy for fellow human beings
and they continue to stand by their values even during testing times.3
INTRODUCTION
WHAT ARE THE CHANGING PARADIGMS?
Major-General Sir Gerald G Giffard, Knight Commander (KCIE)
[Indian Medical Service (IMS), retired] read before the East India
Association, at Caxton Hall, on November 17th 1924 about the future
of medicine in India.1 He informed that the practice of medicine
in India is attractive but observed that Indians “…have hardly any
aptitude for medical research.” He said that native physicians had
spent all their money they could command on their education
and therefore could not start independent practice. Therefore,
they got stagnated in great towns and became fully dependent on
government employment. He along with the Raja of Panagal, the first
minister of the Madras government developed several schemes to
support physicians with a house for a specified number of years, free
medicines and apparatus, and gradually diminish the subsidy over a
period of time allowing them to be successful in their practice.
Visionaries like them initiated the golden era for the physicians
in our country. Today, the practice of clinical medicine is of high
Today, we can identify disorders where clinical signs and symptoms
are very subtle that they may not be suspected in the first place.
Technological advances also help in establishing the etiology of a
clinically proven disease objectively at the earliest instant. Timetested conventional management protocols are continuously being
tested by the shifting social values, economic situations and political
circumstances.
The knowledge of physicians is expected to transcend beyond
their geopolitical boundaries in the field of medicine and biology.
Pharmaceutical industries, diagnostic aids, medical equipment
technology and insurance often dose the physicians with strategic
snake oils, discredited nostrums and unproven treatment benefits,
citing tailored evidence-based medicine. Unlike the previous
generations, physicians are often tempted—“why do we not try
them?” Therefore, it is often difficult for them to make conscientious
decisions considering the cause, consequences and costs in clinical
General
medicine. The financial experts also make them work on numbers,
calculate earnings before the deduction of interest expenses,
taxes, depreciation and amortization (EBDITDA), and make them
answerable to the creditors in the corporate health care institutions.
HOW WAS THE ROAD TRAVERSED?
In 1897 the father of Internal medicine, Sir William Osler, spoke of the
field of medicine and its uncertainties that, since time memorial, “To
have striven, to have made an effort, to have been true to certain ideals
- this alone is worth the struggle…. Gentlemen, if you want a profession
in which everything is certain you had better give up medicine.”
Much earlier our ancient physicians taught that “Dividho
jayate vyadih, Sariro manasasthatha, Parasparanz tavorjanma,
Nirdvadvam nopalahhyate” (Diseases occur both physically and
mentally and even though each part might be dominant, they cannot
be compartmentalized).
Their understanding in medicine is “Sukarthah sarvabutanam,
Matah sarvah pravarthayah, Sukham ca na vina dharmat, thasmad
dharmaparo bhavet” (All activities of man are directed to the end of
attaining happiness, whereas happiness is never achieved without
righteousness. It is the bounden duty of man to be righteous in
his action). In Charaka Samhita, it is given that the physician who
regards compassion for living beings as the highest religion fulfills his
mission (Sidhartah) and obtains the highest happiness. He confers
the highest form of religious blessings to the physician who snaps the
snares of death for his patients.
WHO ARE OUR COLLABORATORS?
The Field of Medical Imaging and Technology
Conventional medical imaging modalities like X-ray, ultrasound,
computed tomography, interventional radiology and magnetic
resonance imaging (MRI) always help us to visualize the anatomy
of the body precisely. The molecular dynamics, biochemistry
and physiology of the body are better explained with singlephoton emission computed tomography (SPECT) and positron
emission tomography (PET) studies.4 Fluorescent dyes are being
also developed to tag biomolecules and study them without the
use of ionizing radiation.5 Therapeutic interventions like selective
embolization procedure use of high-energy radiation like beta, alpha,
electrons and protons are also available in the armamentarium of the
physician.6,7
The Field of Molecular Medicine and Surgery
(with DNA Scissors)
In molecular medicine, we visualize, characterize, quantitatively
measure and modify the biological processes at cellular and
molecular levels. We use a piece of DNA encoding reporter protein
molecule with a readily measurable phenotype and that can easily
be distinguished from background molecules (reporter gene) for
this purpose. With this, we can also regulate the transcription,
post-transcription regulation of gene expression, protein-protein
interactions and the trafficking of molecules within the cells.
Treating disorders with alpha-particle emitters like radioactive
astatine, which causes minimal collateral damage to the surrounding
proteins8 is now possible. Cell biologists have also designed laser
scissors and tweezers with which they can operate on the molecules
and DNA inside the cells in order to understand and manipulate the
cell physiology.9,10
The Field of Artificial Intelligence and Nanomedicine
The concept of artificial intelligence came into existence in the mid
1950s, and in this we attempt to emulate intelligence in natural
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Section 22
and artificial environments alike. This helps us to understand
the multitude of complex interactions in biology, especially, the
processes involved in synthetic and systemic biology. In synthetic
biology, we design and construct new biological components and
devices in order to improve upon the existing biological system for
the benefit of mankind.11
In nanomedicine, particles measuring from 1 nanometer (nm)
to 100 nm in length and 5 nm to 50 nm in width (a white blood
cell is more than 10,000 times bigger) that can be produced by self
assembly and self-organization processes inside the living system or
by chemical method, often coupled with the expertise from artificial
intelligence. These are essentially nano-sized machines that can be
designed to act as transporters, actuators and motors.
Therapeutic agents like drugs, proteins, vaccines, plasmids, etc.
can be transported to the specific target cells and delivered with a
definite purpose using these nanocarriers. We are working on a
model to introduce such nanocarriers into the lymphatic system,
maneuver them toward the target organ and optimally time the
delivery of drugs.
These nanoparticles are highly specific to the target tissue,
stealthily evade the immune response, nontoxic, highly stable in the
physiological milieu, biodegradable and deliver the consignments
across the cell barriers. Apart from drug delivery, they are also capable
of recognizing the diseased cell, establishing the diagnosis, site and
extent of the disease and monitoring the response to treatment.
These are the preliminary steps for the evolution of personalized
medicine in the future.12
Nanoscale molecular bearings, molecular gears (Figure 1), neon
gas powered molecular motors, tubes and propellers have led to the
design of self-assembled monolayered mechanical parts from DNA
and protein directed assembly lines. NanoRobotics Laboratory of
Ecole Polytechnique in Montreal is using an MRI system as a means
of propulsion for a microrobot in the blood vessels. This has led to the
designing of the artificial mechanical red blood cells “respirocytes”
(Figure 2) capable of delivering 236 times more oxygen to the tissues
than the RBCs that can keep the tissues adequately oxygenated for at
least 4 hours, even in the absence of respiration due to various clinical
conditions. “Microbivores” (Figure 3) are artificial mechanical
white blood cells that can digest and destroy the harmful pathogens
in bloodstream. Telescoping robotic grapples emerge from silos in
the device surface to grab and transport the pathogen in front of the
digesting port, where the pathogen undergoes enzymatic breakdown
into mono-residue amino acids, mononucleotides, glycerol, free fatty
acids and simple sugars.13 Alan M Turing aptly sums up the scope as
“We can only see a short distance ahead, but we can see plenty there
that needs to be done.”
The Field of Tissue Engineering and
Aerospace Medicine
Engineering the tissues and other biological substrates provide
an alternative option to repair the conventional healing processes.
Such products have three main components: (1) the isolated cells,
(2) the extracellular matrix and (3) the signaling proteins (growth
factors). They provide the scaffold materials with cell adhesion and
proliferation factors that encourage tissue regeneration. They have
extensive applications in orthopedics and cardiovascular system.
Implantable devices like stents, retinal implants for restoration of
vision and hearing, restore bladder and bowel functions in neuronal
injuries and brain computer interfaces for combating mental
retardation. There is a renewed interest in the study of telomeres at
the chromosomal ends and studies are emerging that the length of
telomeres is directly related to the process of aging and longevity.14
Space medicine understands the biophysical and molecular
modeling in zero gravity along with prolonged exposure to high-
Section 22
Chapter 159 Quo Vadis Medicine... The Road Ahead for Physicians
Figure 3: Artificial phagocytes the “microbivores” can fully eliminate
infections and repair tissues in the body within few minutes to hours and
help physicians to tackle almost entire range of infections
Source: Freitas RA. Microbivores: artificial mechanical phagocytes using
digest and discharge protocol. Zyvex. 2001;634-45 preprint. http://www.
rfreitas.com/Nano/Microbivores.html.
Figure 1: A molecular planetary gear is a mechanical component that
might be found in the medical nanorobot. The gear converts shaft power
from one annular frequency to another. The casing is a strained silicon
shell with predominantly sulfur termination, with each of the nine planet
gears attached to the planet carrier by a carbon-carbon single bond. The
planetary gear shown here has not been built experimentally but has been
modeled computationally
Source: © 1995, Institute for Molecular Manufacturing (IMM).
and vision loss are commonly encountered challenges. As a
consequence, we developed newer biomaterials and prosthesis as
well as medical devices like the implantable defibrillators, pace
makers, light weight wheel chairs, diabetic foot mapping, walkers,
radiological imaging devices and telemedicine facilities. We now can
also develop smart medical technologies that are compact, light and
energy efficient.15
The Field of Health Care Economics and
Telecommunication
Figure 2: The artificial red cell—the respirocyte that mimics the functioning
of the natural red blood cells. About 5 trillion individual respirocytes
suspended in 5 ml of 50% saline suspension when injected intravenously
can match the gas carrying capacity of the patient’s entire 5.4 liters of blood
Source: Freitas RA. Exploratory design in medical nanotechnology: a
mechanical artificial red cell. Artif Cells Blood Substit Immobil Biotechnol.
1998;26(4):411-30.
http://www.foresight.org/Nanomedicine/Respirocytes.
html.
energy cosmic radiation particles from the stars to help in survival
during prolonged space missions. Loss of bone density and muscle
mass, changes in circadian rhythm, proprioceptive problems, sleep
disturbances, cardiovascular changes, immune system depression
Rapid population growth in our country, increasing life span and
age-related disorders, enhanced health awareness promoted by the
media, varying degree of disposable income and literacy parameters,
heterogeneous distribution of medical institutions, insurance and
medical tourism are beginning to have a significant impact on the
current practice of medicine. Unlike the west, more than 80% of the
health care expenditure is met “out of pocket” by the patient and
relatively minimal contribution comes from the government sources.
Significant increase in noncommunicable and lifestyle disorders like
diabetes, anemia, hypothyroidism, obesity, cardiovascular disorders
and cancer are common nowadays.16
There is increasing Foreign Direct Investments in health care
institutions, Mergers of stand-alone practices into corporates, high
degree of clinical trials and poor effort in basic medical research,
migration of large section of population across the country due to
occupational necessities like construction and other developmental
works also shake the very foundation of ethics in the current practice
of medicine.17
Corporatization of the medical institution brings the best of
technology within the reach of the common man. Their accreditation
to bodies like the International Organization for Standardization
(ISO), National Accreditation Board for Hospitals and Health care
Providers (NABH), Joint Commission International (JCI), etc. ensures
continuity of quality care to patients. However, there is a possibility
of decreasing income and increased administrative expenses for
the physicians. There may be pressure on physicians to enhance the
use of supportive medical services in the name of evidence-based
medicine and the importance to clinical acumen could be slighted.
Nonphysician managers who were trained by business gurus, who
have no idea of compassion, empathy and human values, are also
697
General
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likely to deviate health care administration from patient-centric
physician driven model to a profit-oriented revenue generating
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WHY PERSONALIZED MEDICINE?
Personalized medicine involves administration of a drug exclusively
tailored to the genetic makeup of an individual, so that the drug is
delivered with maximum safety and effectiveness to get the best
possible clinical outcome. In India, there is a vast population of
diverse genomic makeup and it requires extraordinary energy
and resources from the government and the industry to deliver
personalized medicine. It practically involves diverse scientific fields
to work together toward a common goal—integrating the progress
in the field of information technology, clinical information from
individuals, physicians, hospitals, diagnostic centers, pharmacies,
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WHERE ARE WE HEADED?
We have seen that the road ahead for the physicians is smooth and yet
challenging, with the best of technology and talents at our disposal.
The Indian government has declared a perennial requirement of
physicians for optimum health care delivery, both in urban and
rural areas—more in rural areas, despite the mushrooming of
medical colleges in recent times.19 Gone will be the days of organ
transplantation and infusion of the body with loads of toxic drugs.
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organ preservation and regeneration of failed components, with the
help of molecular and personalized medicine. More and more basic
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In the pursuit of excellence in medicine, physicians must have
rigor and commitment to evidence-based medicine, up-to-date
information-management skills, a commitment to lifelong education
for themselves, their patients, and their colleagues and trainees and
have complete command over the technology. The society sees
them as an embodiment of the knowledge and professionalism. The
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and market driven economy is likely to divert our vision and create
an illusion of prosperity. Due diligence has to be exercised while
balancing the art of clinical medicine and the science of modern
technology.
“Water flows in the river, but the river cannot drink it.
It is for the humanity.
Cow yields milk, but it cannot drink it. It is for the humanity.
Tree yields fruits, but it cannot eat it. It is for the humanity.”
~ Bhagwan Sri Sathya Sai Baba’s comments
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