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"Modern" medical education is about to have an important birthday. In many ways, it began with the Flexner Report, which was published in 1910 by the Carnegie Foundation for the Advancement of Teaching. The Flexner Report was revolutionary in its assertion that medical practice should be based on scientific understanding. For the past ninety-nine years, most aspiring physicians have followed Flexner's prescription of two years of preclinical science education, followed by two years of clinical experiences. In the 1960s, the Duke School of Medicine uniquely modified this formula by requiring only one year of didactic science education, allowing students to use the extra year for research.
Biomedical science advanced rapidly over the twentieth century. Microorganisms were shown to be disease-causing agents, and new drugs and vaccines were discovered to combat them. Inborn errors of metabolism, diseases caused by a lack of specific enzymes, were described as genetic defects in the body's biochemistry. Even protean mental illnesses were described with strict criteria and catalogued accordingly. Throughout the decades, medical education focused on diseases as discrete, largely independent alterations of the human condition. Students were taught that a sick patient usually had one disease, but over time, might acquire additional diseases layered on top.
A century after the Flexner Report, medicine and medical education are again undergoing a transformation. Diagnosis is no longer binary; we can't simply say one does, or does not, have a disease. A growth in the intestine, for example, may have features that fall anywhere along a spectrum, from entirely benign to precancerous, to cancerous, to metastatic. In part owing to our ability to detect pathological processes early and follow them over time, medicine is becoming less disease-centered and more patient-centered. We can now examine a patient's genes, use a rapidly expanding repertoire of genomic knowledge to predict whether she is at risk for medical problems, and take advantage of that genetic information. Although we do this now in a rather primitive way, we're learning fast.
The Flexner Report also marked the start of an era in which allopathic medicine, based on the natural sciences, became more widely accepted than homeopathic, chiropractic, and osteopathic medicine. Here, too, old lines are blurring today, as we accept that traditional healing approaches can also be effective in promoting wellness. Acupuncture is a good example—although poorly understood in scientific terms, its benefits are now widely recognized by mainstream physicians. Approaches referred to as "alternative" or "integrative" medicine are increasingly being added to the modern physician's treatment playbook.
Medical students expecting their degrees in 2034 will understand how our bodies function in health and in disease far better than ever before. Traditional tests for cholesterol, blood sugar, and other indicators of well-being likely will be supplanted by complex metabolomics and proteomics tests that monitor thousands, rather than dozens, of biochemical clues. The complex data sets developed through genomics, metabolomics, proteomics, and other yet-to-be-defined "-omics" (a neologism referring to the totality of a biological system) will allow physicians and patients to work together in unprecedented ways to predict an individual's personal risk and prevent the onset of clinical symptoms through preemptive lifestyle changes and proactive treatments.
Increasingly, traditional x-rays and scans will be supplanted by imaging studies that not only show the anatomical structure of our parts but also allow us to visualize the biological activities of the brain, heart, and other organs in real time. Scientists will take advantage of futuristic approaches such as nanobiology, structure-guided synthetic chemistry, and function-guided synthetic biology to develop designer medicines that have very precise, laser-like effects. It's not beyond imagination that we might even find ways to repopulate our bodies with health-promoting, rather than disease-promoting, germs.
Instead of relying on black-and-white definitions of a normal state and an ill state, medical students of the future will learn to appreciate a complex gray scale of health and un-health. Rather than dealing with relatively late-stage disease complications, the emphasis likely will be on preventing and reversing pathological processes before they have a chance to do great harm. In fact, it's likely that the very terms "health" and "disease" will be anachronisms twenty-five years from now.
For the Duke School of Medicine, this means giving our students more opportunities to learn about human health in settings where groundbreaking discoveries happen and are rapidly translated for clinical use. This future is high tech, certainly. But I hope that we will continue to admit students who truly care about others and liberally share their skills and their intelligence. And I hope that no matter how advanced medical technology gets, it will still be true that a simple touch—a doctor's hand on a patient's arm—will have a very powerful effect, and that our graduates will use that power generously and compassionately.
