Medicine at the dawn of the metaclinical era

Abstract

Over the many centuries that lie between Hippocrates and modern clinical practice, medicine—and clinical medicine in particular—has undergone dramatic progress. Numerous and varied contributions made by individuals and groups to clinical observation, rigorous experiment, and the systematic study of pathophysiology and therapeutics over the whole range of known diseases have transformed our profession. Hippocrates, the acknowledged ‘father of medicine’, laid the groundwork for the development of modern medicine, stressing the importance of evidence-based practices, medical ethics, observation, and a holistic approach to patient care. Some of his best known aphorisms, such as ‘first, do no harm’ and ‘prevention is better than cure’, along with the classic text of the Hippocratic oath, have for a long time determined the core values and principles of physicians and medicine. Since Hippocrates’ time, medicine has evolved to reach unimaginable heights, boosted by a whole spectrum of developments in the sciences—pharmacology, genetics, biostatistics, materials technology, and information technology, to name but a few. As a result of these developments, today’s medicine, the so-called ‘evidence-based’ medicine, is decisively technology-oriented. Advanced imaging, and a deep exploration of all kinds of omics in different patients, including the use of a large range of biomarkers, can discriminate among different phenotypes and, to a significant degree, make personalized medicine possible. Nevertheless, despite all these amazing advances, applied medicine—diagnostic and therapeutic—is still dependent upon human insight and judgement, as shaped by the knowledge and experience of human physicians. However, recent developments have been earth shattering. At an exponentially increasing rate, new dimensions of digital medicine—specifically the fields of artificial intelligence (AI) and big data analytics, plus a wide range of new diagnostic products, mainly in the form of wearables—have opened up a radically different future perspective in medicine and cardiovascular medicine in particular. As a result, we now see a radical differentiation between clinical and metaclinical medicine, with on the one hand the limit of human capabilities and judgement and on the other the capabilities of AI. What we are calling ‘metaclinical medicine’, as a term to define medical developments from this point on, is the entire spectrum of diagnostic and therapeutic medical science that will increasingly depend on digital technologies, and especially AI, while human participation in observations and decision-making will diminish to play a less decisive role (Figure 1). The evolution of medicine. From the era of Hippocrates to modern medicine and beyond to metaclinical era The term ‘metaclinical’ mirrors a term believed to have been coined by a curator of Aristotle’s works, using the Greek word ‘meta’, meaning ‘after’. Lacking an appropriate title for the book that came after Aristotle’s work on Physics, Andronicus of Rhodes labelled it ‘Metaphysics’, the one after Physics, and the name stuck. An alternative translation of ‘meta’ might be ‘beyond’. The notion of a kind of medicine enabled by convolutional neural networks, with capabilities far beyond those of humans, is no longer a science fiction plot, but an actual reality. Validated research over the last 5 years, focusing on electrocardiography and on AI-enabled imaging, has opened up a vast panorama of developments in the immediate and more distant future, taking advantage of the superhuman capabilities of AI.1–4 At the dawn of this new era, to extend our speculation even further, we must take account of the rapidly evolving AI-based subdomains that can be expected to make a major contribution to the future development of metaclinical medicine. The authors of this article judge that the following areas are of sufficient scale, importance, and perspective to extend beyond the concept of a simple medical support tool and are increasingly being recognized as game changers in metaclinical medicine.5–7 Big Data analytics, for the evaluation of new genotypes, phenotypes, pattern recognition, and new trends. Structured data and clinical decision models. Precision medicine based on the concept of ‘Digital Twins’. Artificial intelligence-enabled tools for advanced diagnostics, far beyond human capabilities. The metaverse as a game changer for medicine. Development of in silico clinical trials. All the above, and more, are destined to be drivers of medicine, steering diagnostics and therapeutics—not to mention surgery by AI-enabled robots—into uncharted waters, where human abilities will inevitably pale in comparison with those of the new technologies. It is to be expected that the emerging realities and prospects will highlight positions and contrasts among experts in the field of medical science, dividing them into two main camps. The first camp consists of those who currently doubt whether AI-enabled medical practice will partially or totally replace the human physician in the foreseeable future. The main arguments here relate to the current nature of AI, which more accurately could be called ‘simulated intelligence’. Briefly, they argue that most human activities, including medical practice, also depend on other abilities, such as intuition and creativity. Until our computers can reproduce or simulate these types of thinking, the computer physician will remain a dream. The authors of this article belong to the other camp, though they do not dismiss the significance and logic of the above arguments. Observing the exponential expansion of digital media that has already occurred, they argue that the evolution of medical practice will be towards a metaclinical era, where AI-enabled clinical observation, analysis, and synthesis will progressively limit the role of human judgement and decision-making in all forms of diagnosis and treatment. In other words, we expect that the essence of diagnostic and therapeutic medicine, as it has traditionally been structured through the centuries—and especially lately, with the assistance of advanced scientific markers and tools—will change to such an extent that human observation and reasoning will fall noticeably short of AI and Big Data analysis. Inevitably, at this point, the question arises as to the future role of the human physician. This will undoubtedly change. We hope and believe that physicians, as treaters of bodies and minds, capable of displaying a high level of mindfulness, rectitude, and sympathy in the management of their patients’ feelings, will support them more effectively, building a more meaningful relationship than is usually the case today. Apart from all the above, there will certainly be a plethora of moral, regulatory, legal, and philosophical issues associated with the new realities that will accompany developments in the centuries to come. But as Heraclitus (544–484 Bc) first observed, ‘Everything flows,’ and our planet is a world of change. All authors declare no conflict of interest for this contribution.

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