The n e w e ng l a n d j o u r na l of m e dic i n e

edi t or i a l s

A Glimpse of the Next 100 Years in Medicine

Isaac S. Kohane, M.D., Ph.D., Jeffrey M. Drazen, M.D., and Edward W. Campion, M.D.
Over the past year, the Journal has commemorated
200 years of publication and the astonishing
progress made since 1812 in the science and
practice of medicine. Thanks to digital technol-
ogy, our anniversary celebration has had a wide
reach, with more than 1 million visits to the
NEJM200.NEJM.org site; many viewers of our
documentary video, Getting Better; and large num-
bers of viewers of our simulcast symposium,
Dialogues in Medicine. As the Journal’s 200th year
comes to a close, we want to think about the
changes and challenges that medicine faces in the
decades ahead. Although it is foolish to attempt
specific predictions about the future, it would be
unwise not to think about the emerging trends,
new opportunities, and the principles that should
guide the medicine of the future.
In the decades ahead, the pace of biomedical
discovery will accelerate. The state of an individ-
ual person will be characterized with increasing
precision from the molecular level to the genom-
ic level to the organ level and by interactions
with medications, nutrients, the microbiome,
therapeutic devices, and the environment. This
precision medicine1 will become possible be-
cause of huge data sets on large populations,
with millions of characterizations of each person.
Study populations will grow to millions, which
will allow observational studies with novel statis-
tical methods that will allow discovery of use-
ful, reproducible patterns and relationships from
these data. This will be possible because virtu-
ally all the data will be in an advanced infra-
structure of electronic health records (EHRs) that
includes input from physiological monitoring,
which is already starting to become part of the
management of chronic diseases and of guide-
lines for prevention and fitness. Therapeutic and
monitoring instruments will continue to become
smaller, smarter, more interactive, and more
connected to the health information infrastruc-
ture. However, the quantum leaps will come not
from the devices but from inferences drawn from
the data.
The size and complexity of this multidimen-
sional characterization of patients will lead to far
more complex diagnostic and prognostic catego-
ries than are currently in use. The multivariate
descriptors of large populations will allow strat-
ification of a kind seen only in the most recent
genomically informed clinical trials.2 Massive
data crunching will yield analytic or algorithmic
formulas that will be useful for clinical purposes
even though they defy easy summary in a lan-
guage most of us can understand. Complex but
empirically validated algorithms will be embed-
ded in EHR systems as decision support tools to
assist in everyday patient care. Those manage-
ment algorithms will evolve and be modified
continuously in accordance with inputs from on-
going clinical observations and from new re-
search. Clinical decision support algorithms will
be derived entirely from data, not expert opinion,
market incentives, or committee consensus. The
huge amount of data available will make it possi-
ble to draw inferences from observations that will
not be encumbered by unknown confounding.
Both patients and payers will demand in-
creased transparency, particularly for new ther-
apies that will have to be monitored in ongoing
studies of comparative efficacy. This will increase
the pressure on regulatory authorities for greater
plasticity that will allow them to adapt rapidly,
accurately, and decisively to the evolving under-
standing of the merits and risks of different
therapies. Scientists, physicians, and the public

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 editorials

will demand that all the primary data be made
public, along with the analytical tools necessary
to reanalyze, test, refine, and build on them.
Data security will have to evolve and thereby win
the public’s trust with new techniques that will
do what now seems impossible: guarantee pro-
tection of privacy while providing detailed infor-
mation about each person. Societies will come
to accept that comprehensive knowledge of dis-
ease, prevention, and effective treatment is an
essential public good.
Biomedical research, data technologies, and
clinical care all require resources, but the era of
shifting more and more economic resources to-
ward health care is going to end. The medicine
of the future will focus on more efficient use
of resources to prevent disease, with the goal of
delivering what provides the best value for the
patient who needs treatment. The future of medi-
cine also depends on reducing the enormous dis-
parities in health, particularly those between the
richest and the poorest countries of the world.
A basic standard of sound medical care will be-
come an expectation of every society. Research-
rich countries may come to see that achieving
basic health care throughout the world is a strat-
egy to promote stability and peace. The increas-
ing power of information and communication
technologies can help find ways to improve
global health. However, that goal also requires
the educational and economic development that
are essential for societies to achieve a reason-
able standard of health. The moral mandate
here only becomes stronger as clinical progress
continues to accelerate in developed societies.
The high-technology, information-rich med-
icine of the future will provide powerful and use-
ful tools for clinical medicine. The medicine of
the future will not, of course, solve all problems,
and it cannot prevent violent or self-destructive
human behaviors. Patients will continue to rely
on physicians and the medical community for
the guidance, support, and help that only a
skilled and caring heath professional can deliver.
The medical community must provide direction
to ensure that powerful new technologies are
used to benefit the health of all. As advances in
science and technology continue to bring disrup-
tive changes, the Journal must continue to evolve
creatively in order to continue in its mission of
inspiring discovery and advancing care. As we
head into this medicine of the future, the Journal
should remain true to the principles that were
set down by its founding physicians two centuries
ago: “The Journal will always be open to the accu-
rate observer of nature, the useful experimenter,
and the rational therapist.”3
Disclosure forms provided by the authors are available with
the full text of this article at NEJM.org.
From Boston Children’s Hospital and Harvard Medical School
— both in Boston (I.S.K.).
1. Committee on a Framework for Development of a New Tax-
onomy of Disease. Toward precision medicine: building a knowl-
edge network for biomedical research and a new taxonomy of
disease. Washington, DC: National Academies Press, 2011.
2. Patel JP, Gönen M, Figueroa ME, et al. Prognostic relevance of
integrated genetic profiling in acute myeloid leukemia. N Engl J
Med 2012;366:1079-89.
3. Thomas B. Wait and Co. Proposals. Boston Patriot. Vol. 6.
No. 9. September 28, 1811:3.
DOI: 10.1056/NEJMe1213371
Copyright © 2012 Massachusetts Medical Society.

Brain in a Box
Allan H. Ropper, M.D.

The brain, despite its sophistication, resides in a
rudimentary container. The rigid cranium re-
stricts enlargement of its contents, so that intra-
cranial pressure rises rapidly as brain volume
expands. When pressure becomes greatly elevat-
ed, cerebral blood flow is impeded, and the re-
sult is brain death. For this reason, the reduction
of elevated intracranial pressure is a central
theme in the management of traumatic brain in-
jury, cerebral hemorrhage, and most other intra-
cranial mass lesions. The widely adopted recom-
mendation of the Brain Trauma Foundation is to
keep intracranial pressure below 20 mm Hg in
order to avoid poor outcome1; adherence requires
that the pressure be measured directly. This advice
and the assumptions that underlie it are tested
in the report by Chesnut and colleagues in the
Journal.2 They compared therapy based on the
measurement of intracranial pressure with a treat-
ment regimen that was regulated more simply with
the use of clinical observation and computed to-
mographic scans; the outcomes were the same.

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