HARVARD MEDICAL SCHOOL PRIMARY CARE REVIEW

Precision Medicine & the Pivotal Role of Primary Care to Shape the Future of Healthcare

October 14th, 2020

"My dear, here we must run as fast as we can, just to stay in place. And if you wish to go anywhere, you must run twice as fast as that." - Lewis Carroll, Alice in Wonderland

This is the only quote which I clearly recall from my early childhood, and it took me several years to fully understand its meaning. It is truly universally applicable, and physicians are not exemptI believe most of us are undeniably permanently running at least twice as fast, attempting to contribute to the (r)evolution of medicine, and also not lag behind.

I remember watching in awe how the doctor in The Jetsons could connect to patients’ homes via monitor, digitally examine patients, and use a spaceship-like computer to create exact treatment plans for each specific individual. Predicted for 2062, this futuristic dream has not only become possible but become standardized in some settings.

What is precision medicine?

Precision medicine has evolved rapidly from a visionary term to an essential, driving directive in medicine: every patient should be able to receive the right treatment at the right time. Personalized health assessments allow clinicians to tailor prevention and treatment plans to individuals’ unique characteristics, including their genome sequence, microbiome composition, health history, lifestyle, diet, and an abundant number of further internal and external influences. This requires clinicians obtain various forms of data, including metabolomics (chemicals present in the body at certain points in time), the microbiome (collection of microorganisms or bacteria within or on the body), and health and psychosocial data about the patient, including each patient’s social determinants of health. One might compare this to obtaining a picture of a person from every possible perspective in order to customize the most effective prevention and treatment.

Primary care providers are challenged daily with the “silver tsunami”—the increasing number of elderly patients in our global society—and this is key to precision medicine, as aging is the root cause for many chronic diseases and loss of physiologic function. Prevention has been a crucial part of primary care for centuries but has experienced a shift towards personalized medicine in recent decades. With the novel tools of omics (like genomics and metabolomics), comprehensive imaging, and artificial intelligence—that is, the integration of biology, technology, and medicine—we shift from prevention towards precision, from personalized to individual care.

Geroscience and biogerontology—the fields of medicine that address aging—study the process of deterioration with age, from the molecular to the system levels, ultimately providing the insight needed to design viable healthcare solutions for the aging population.

How does precision medicine relate to health equity?

As we advance precision medicine, we must also consider its potential effects on health disparities. Globally, there are vast inequities in health outcomes, particularly related to race/ethnicity and socioeconomic status. With precision medicine, there is the potential to address and reduce these disparities, and it is up to the scientific community and core stakeholders for how this new field can be exploited towards the common good.

In many countries, there has been a historic lack of inclusion of racial and ethnic minorities in scientific research, and thus, the first step in addressing potential health inequities in precision medicine is intentionally diversifying this research. The National Institutes of Health (NIH) launched the All of Us Research Program to address this disparity, and it aims to enroll at least one million participants of varying race, ethnicity, gender, age, socioeconomic status, disability, and more, in order to gather data on a wide variety of health conditions.

And further, we must also consider the accessibility for patients… and thus, most precision medicine leaders underline the importance of popularizing and democratizing precision medicine.

Aging biomarkersbiohorology & deep learning in precision medicine

“Oh my fur and whiskers! I'm late, I'm late, I'm late!” -The White Rabbit, Alice in Wonderland

I think of biohorologists as the White Rabbits of healthcare—they live and breathe the measurement of the passage of time in living systems… and they do this by creating biomarkers of aging. Thus, it’s now possible to tell from nearly every cell in the body how old we are, and to the nearest month.

This concept is extremely novel—aging clocks were first published in 2013 and deep aging clocks in 2016. And deep aging clocks can be used to identify novel therapeutic targets, evaluate the effectiveness of medical interventions, and predict health trajectories and mortality. What started as a collaboration between mathematicians and biochemists evolved into deep learning—an approach that uses artificial intelligence to develop deep age predictors with the goal for this research to be translated into medical contexts where clinicians can apply it to patient care.

What sounds far from the daily care we offer is in fact closer to the dream some of us have assumed: deep aging clocks can be used to predict the efficacy of medical interventions and prognoses, thereby developing the best possible preventive and treatment measures.

“The youth must fly.” -Mom

My mother gave me one sentence when I left home at an early age: “The youth must fly.” She brought the old wisdom that “parents should give their children the wings and roots” to fly to a new level. Twenty years and three continents later, I understand that she referred to an important skill that is so crucial in medicine: we must embrace this ultrafast progress in order to bring such novel solutions to our patients. Our present times prove that what we consider as a futuristic utopia is happening, or soon to come.

**Feature photo obtained with standard license on Shutterstock.

 

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Eva Bischof 2

Evelyne Bischof, MD, is a Europe, China, and US-trained practicing internist and Associate Professor at the Shanghai University of Medicine and Health Sciences. She is passionate about implementable precision medicine solutions.

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