THE FUTURE
OF
MEDICINE

Many months ago, before the COVID-19 pandemic struck a seismic blow to the routine activities of most of humanity, I had finally felt my meandering musings on this blog had rightly tethered themselves to a theme. I would hone my focus and write about the future of medicine. I recognized that both lay and specialty periodicals that examine how technology affects societies and individual behavior were neglecting future medical breakthroughs for the furtive field of thought I believed it was. My background as a physician afforded me insight into specifics about the feasibility of these technologies, but it was my interest in spirituality that made me curious about the psychological and societal implications of the widespread adoption of technologies that would alter the human experience. This naturally lends to some techno-skepticism. After all, we live in an age where time and again, non-medical technologies that were once thought to be liberating, equalizing, and progressive have in fact been shown to be manipulating, polarizing, and hazardous (I’m talking about you again, Facebook!)

I’ve been compiling a list of topics to write about on this blog for the last nine months, a to do list that’s grown so long that it now exceeds my capacity to complete them in an efficient manner. One idea about the future of medicine that I’ve been meaning to get to is the topic at hand, future pandemics, but I wasn’t sure how to approach the issue. Should I begin with a cursory review of one of the worst pandemics in history, the 1918 H1N1 flu that killed 50 million people worldwide, and segue into conjecture about what factors could make such an event easily happen again? Or should I tackle the “known unknowns” about what sort of organism might cause the event, what part of the globe it would likely come from, and what sort of damage it would do to people’s health and well-being? Alternatively, I could paint the worst-case scenario: the death of a sizable portion of humanity and the ensuing collapse of social, moral, and economic order.

When I started this blog last May, I wanted a place to write freely about my obsessions. I’ve always been curious about the big picture questions in life. Why are we here? What are we to make of this existence? What are our relationships to one another and the things we surround ourselves with? The way I phrased it on my twitter profile was “I write about the nexus of science/medicine, spirituality, & technology.”

“I can’t figure out what your theme is,” said a colleague of mine who had happened upon my posts early on. He was right. They were a bit scatter shot. I wrote about nuclear energy and transhumanism, then about meditation and bio-observant devices.

As the posts matured, however, almost everything that interests me convened around one topic. Which is why I’ve decided to land a theme and stick to it. The future of medicine.

Trust is a foundational value for any civilization. When you arrive at your local Kwik-E-Mart, you want to know when you hand over your dollar bill, that your 99 cent can of Arizona Iced Tea isn’t filled with battery fluid and will be as fresh and saccharine as the first time you had it. The cashier on the other side of the counter wants to be assured that your dollar bill is an actual dollar bill rather than a counterfeit one that won’t work when he has to purchase the mango chutney his wife keeps hounding him to pick up on the drive home. Without trust, any number of human to human transactions would be fraught with doubt, fear, and one too many side-eyed glares.

A few weeks ago, I looked at an arterial blood gas reading in my hospital’s electronic medical record (EMR) for a patient whose care I took over when he suddenly and strikingly became short of breath. I immediately noticed something odd. The numbers were perfect. Usually, when something is catastrophically awry with someone’s biology, an arterial blood gas will let me know, the numbers in the EMR blaring a firetruck red so that I’ll be properly alarmed by the physiologic offense. But what I read was a normal blood pH, a normal carbon dioxide, and a normal oxygen saturation. There wasn’t a hint of lactic acidosis, an organic acid that reliably spills from tissues at times of profound stress.

It’s 1985. Summer’s around the corner, but since it’s SoCal, it never really left. In the outdoor courtyard where I, my schoolmates and the seagulls have been eating lunch every day of the school year, I hear a new taunt that carries over the stale cheese pizzas, past the smushed PBJs and into my receptive ears. I’ve been a collector of novel disses most of my short life and this one is as fresh as the guano on the blacktop. I only catch the latter half of the altercation.

“Oh yeah,” says Brad, the surfer with the sundrenched bangs. He’s staring down a guileless boy who was a few inches shorter than him. “Well, you’re a test tube baby!”

An elderly woman drives to her local store in the early afternoon every Thursday to purchase the week’s groceries. Milk, butter, bread and cheese are her staples. The vegetables vary week to week based on her preference for this dish or that. The fruits that fill her cart never deviate from what can be found in any produce section in any supermarket during any season of the year: bananas, apples, and oranges. On the way to the cashier (she abhors the absence of small talk at the automated scanner), she suddenly remembers that her grandchildren will visit this weekend. She makes a slow pivot for the baking aisle and reaches for the top shelf for a ready-to-bake package of coffee cake. When she reaches overhead, her stance becomes unreliable and she retracts her hand to steady herself. The second time she tries, she gets it, but as she’s pulling the box down, it falls to the ground. She hinges down unaided to retrieve it from the floor. While trying to get upright again, her body fails her. She falls sideways and breaks her hip.

Women hunch over an autumnal bacchanal of color in the foreground of Vincent van Gogh’s The Red Vineyards near Arles. It is the harvest season and the leaves on the vines riot in spasms of color and light as a last hurrah before they brown and depart the stems that held them up, that gave them life. To the right, a creek meanders past, reflecting the evanescent glow of the setting sun. A mysterious figure backlit by the evening sky’s luminescence wades in the creek apart from the grape pickers, staring straight out of the painting, ominously responding to our gaze. I cannot help but think that in this vibrant scene of decline the figure must be death manifest, standing in the river of time, waiting for us to transport our aging selves from our august lives to the great beyond. 

On the 4th of August, 1977, not far from where Van Gogh painted this landscape, Jean Louise Calment took her final breath. She was 122 years old. When she was younger, she recalled meeting van Gogh during this productive period of his life, but he failed to charm her. She thought he was a rude drunk. She bicycled around Arles until she was 100. She ate two pounds of chocolate a week. When she was 117, she finally gave up cigarettes and her daily glass of port. 

I woke up on the morning of December 3rd, 2040 with a sense of relief. Another night had passed and I was alive. I stepped outside for my morning walk. The fog was dense as steel and I could only see but a few feet in front of me. Twenty years earlier, my doctor had taken some blood tests, made me do some push ups, and checked my VO2 max on a stationary bike. She handed me a printout that late fall day. With 98% certainty, I would be dead by December 2040. 

By the time I rounded the corner for the last half-mile back home, the fog had barely lifted. A car pulling out of a driveway screeched to a halt just a few feet in front of me. I leapt back. The driver shot a hand out and waved apologetically. I motioned for him to pass then clutched my arm. A shooting pain pierced the center of my chest. I felt the vessels in my neck engorge and my forehead cool. I fell to my knees as the world spun about, gasping my last breath as the end drew near, as my life left me. 

When we think of illness, our minds veer to macrophenomena that incite symptoms. Sidelined by the flu, we speak of fatigue or feverishness, of achy muscles and breathlessness. But hidden behind these gross symptoms lie a remarkable number of perturbations in physiology occurring at the micro level, phenomena that easily escape our purview since our psyches are more attuned to the downstream effects. After all, its how an illness makes us feel that gets our attention.

Much of modern medicine is interested in exposing and redressing the upstream phenomena: the alterations in immune responses that expose elderly patients to respiratory infections, the imbalance in hormones that allow tumors to thrive, the nuances in cell signaling that predict response to therapies. The problem with many of the treatments used today is that although targeted for a particular microphenomenon, the application requires exposure to completely unaffected locales throughout the body. Most of the chemotherapeutics we give are injected intravenously and expose many otherwise normal happy cells in uninvolved organs to very caustic chemicals. It’s like the fire department flooding an entire city in order to douse an inferno at just one apartment building. Sure you cure the fire, but now the subways are flooded and your new sneakers aren’t fresh.

IIf we’re to believe Hollywood storytellers about our first encounter with forms of life beyond mothership Earth, it will be a violent affair. Non-terran life forms always provoke a sort of panic in the popular imagination, but the reality of what our first meeting with ETs will look like is a lot more mundane. 

In June, NASA announced the Dragonfly mission which will deploy a quadcopter craft to sample Titan, one of Saturn’s sixty-two moons. It’s so cold up there (94K or -290.5 °F) that elements that would be gases here on Earth (methane, ethane, and other hydrocarbons) instead form large liquid oceans upon and under Titan’s surface. Water mostly takes the form of frigid ice while the predominant nitrogen fills most of the atmosphere. Hydrocarbons, nitrogen, and water. Sounds like the perfect soup to conjure up life, no? That’s precisely why I am convinced our first encounter with non-Earth bound life will occur a mere 840 million miles away on Saturn’s largest moon.

There is a ritual I perform on the drive over to a gathering of friends and acquaintances I haven’t seen in a while. Anticipating an evening filled with catching up on everyone’s lives, I take to Facebook to recall the names of children and the titles of jobs. It’s a way to recollect those fuzzy facts that hover at the periphery of my mind like vitreous floaters eccentric to my gaze. The more I try to recall such effervescent data on my own, the farther afield it seems to float away. I’m not entirely happy to have outsourced my memory to a technology, but it is an increasingly common phenomenon in these digital days and it makes me curious about what the downstream effects of such a radical shift in information storage and retrieval means for us all.

The lady was of Russian descent and had returned to my lung clinic seeking advice about a small nodule in her chest that we had been keeping an eye on for the last year. She used to smoke menthols so the threat of lung cancer colored our conversation with a series of what ifs. The nodule had grown on the most recent CT scan. I recommended a biopsy, but I came to expect that she would resist. 

One of the more interesting side effects of practicing medicine for a while is recognizing when doctor think creeps into my everyday approach to problem solving. Before any diagnostic is obtained or any procedure is offered, physicians engage in a ritual of obtaining consent from the patient for what’s proposed. This entails explaining the reason the intervention is being offered, the benefits of the information obtained from the interrogation, but also the risks. Part of the ritual that often gets short shrift is offering alternatives, one of which, doing nothing, appeals to those in denial, those who’ve had enough interventions and don’t want any more (usually the terminally ill), and those who think the risks aren’t worth it. My patient initially chose to do nothing, but I was able to convince her to at least continue monitoring the lesion with subsequent CT scans.

Ever wonder what your brain is up to? There is a dazzlingly theatrical time-lapse clip of neurons in a petri dish recorded over the course of 170 hours that mesmerizes me every time I view it. They light up, bulk up, whisk about and connect with other neurons to form synapses. In concert, their behavior looks like a choreographed dance, all in an effort to create the neural pathways that relay the chemical signals that form conscious experience. The kinetic vibrancy of brain cells busy being brain cells reminds me of one of those vintage street scenes from New York where horse-drawn carriages trudge along, pedestrians jaywalk across the street, small crowds form to stare at the piece of technology documenting it all. We’ve seen this street scene reenacted in Hollywood period dramas, but is it possible to simulate the coordinated biological neural network that constitutes brain activity in silico?

Last fall, after an unhealthy bout of doctor self-denial, I had surgery to remove a small tumor that had grown on my hard palate. Some wayward salivary glands apparently felt deglutition was far too easy for me and partook in the gradual obstruction of my oropharynx. The growth was benign, but it was the first time since being a physician that I traipsed the divide and became a patient myself. Before I learned that it wouldn’t end my life, my mind scribbled doomsday scenarios about what the tumor could do to me. It’s natural, I would remind myself, for patients to construct narratives of the worst possible outcome, but looking back now, what was most striking about my reaction was how I so readily othered the tumor. I behaved like it was an unwelcome invader of my physiology, a derivation from what I considered my homeostatic norm. It was not a part of me and I wanted it out.

But how could it not be me? The thing had arisen from my own cells. Yet it challenged my sense of normality, how I perceived myself as a healthy whole, which in turn led me to think about the nature of self and how the human mind creates artificial boundaries between me and everything else in the universe. The problem of othering a tumor that was clearly a part of me originates as a conceptual problem, namely, the fallacy of self.

For the last half century, we have been told about the decline of religion in America. Church attendance is low, the numbers identifying as religious nones is rising. The trends speak to a waning of religiosity.

Yet in the modern age religious feeling abounds. The faithful are among us. They don’t wear robes or tunics. They won’t don palliums or wield scepters. There is no threat of sandalwood incense accosting your nares. In fact, most of the adherents of this faith are outwardly unrecognizable even to themselves. They cannot grasp the religious sentiment that guides them because they have not yet named it.

The religion I speak of is transhumanism. In my estimation, it is the most prolific yet least acknowledged religion that man has ever espoused. Who is a transhumanist? It is someone who believes in the primacy of progress and technology in augmenting the health, well-being, intelligence, and dominance of the human species. The transhumanist believes that we can utilize technology to alter or hack our own evolution and become better beings than nature alone would allow.

The other day I was in medical ward at my hospital and heard a nurse report that her patient’s heart rate was 35 beats per minute, but that he was comfortably eating his breakfast. This prompted a colleague I was with to inform me that his own heart rate drops into the 30’s when he is sleeping.

“How do you know that?” I asked. He pulled a ring off from his right hand and showed me its inner lining. I’d thought it to be his wedding band, but the side not visible to me when worn, the one that touched his skin, had several sensors that continuously monitored not only his beats per minute, but also his temperature and movement, the latter via an accelerometer and gyroscope.

One of the great misrepresentations conveyed in television and film is the portrayal of death. It is not uncommon for a viewer to witness a skilled medical team routinely resuscitate someone from the precipice of oblivion. In a study from 2015 from the journal Resuscitation, researchers observed a CPR success rate of nearly 70% on two major medical dramas. The rate in real life, however, is about half as good.

Why does this matter? Because how death is portrayed on our screens in some immeasurable way prepares us for how it occurs in reality. If the culture is telling people that the odds of surviving a myocardial infarction, a pulmonary embolism, or a massive stroke is very high, then those people when patients (but more commonly, as family members of patients) are besotted with unreasonable expectations when the catastrophic event finally arrives. Odd, then, that these medical dramas strive for such a high degree of fidelity, yet fail to faithfully portray the most challenging moment of our lives.

The phrase Equanimity of Perception came to me soon after a ten day Vipassana meditation retreat in Kelseyville, California last year. Ask most Californians if they know where Kelseyville is and they’ll shrug. It’s one of those rural towns near the hillier central areas of the state, a viticultural region that doesn’t get enough credit for making the grapes that end up inebriating your hapless Wednesday nights. But the spirit which I came to investigate couldn’t be plucked from a vintner’s vines. The spirit I hoped to encounter was my own.