Christian Pristipino is an interventional cardiologist living in Rome where he works in a public hospital since 2000. He is the Founding President of the Italian Association for Systems Medicine and Healthcare (ASSIMSS) and he is the chairman of several official consensus and position papers from scientific cardiologic societies at the national and European level. He is also the co-editor of a book on systems approaches in ischemic heart disease entitled: “Psychotherapy for ischemic heart disease. An evidence-based clinical approach”.
From precision medicine to systems medicine: clinical and social implications
Due to rising health needs in several populations, for several years medicine has been witnessing a cumbersome transition from an insufficient pre-molecular model of medicine based upon anatomy and clinically-classified diseases, to a more comprehensive perspective that encompasses genetic, epigenetic, biochemical and biophysical processes. The two approaches still coexist; but several contradictions stretch the capacity that each model has to adapt to the other, mainly because, while several similar or identical processes play pivotal roles in different classic clinical syndromes, similar clinical syndromes may exhibit very different underlying processes. The incomplete adaptations of these two models unveil the need for an epistemological approach, which becomes even more evident when striving to personalize healthcare solutions.
The first step in this endeavor has been to develop systems biology approaches, in which - thanks to advances in information communication technology and the availability of high-throughput techniques — comprehensive complex cellular processes have been computed to enhance the potential for in silico experiments and the conceptualization of new cellular alteration models. The natural evolution of this paradigm has been precision medicine, a breakthrough associated with complex network interactions at whole-organism multidimensional level that now are becoming a new target in the shift towards personalized medicine. In particular, complex phenotyping is becoming the new model of description, wherein individual genetic, molecular, tissue, organ and inter-organ characteristics and processes are computed, for the first time allowing for individual and more precise models of function and dysfunction.
Although incipient at the level of systems biology, this shift implies a more thorough consideration of emergence properties and multidimensional feed-back processes in complex systems, and cannot be addressed with classic approaches. Indeed, in humans, very strong interactions between quantitative and qualitative dimensions occur, in which psychological, emotional, cognitive and cultural variables invariably influence disparate biological processes within every bodily system. The result is the need for a combined bio-psycho-social/environmental approach to complex phenotyping. This more comprehensive description is achieved with systems medicine, which will enable a real transition to a more personalized model.
Progress is still in an early stage and ongoing; nonetheless, it will soon require profound reconsideration of several pivotal aspects of disease. At the medical level, key points will include the necessary re-classification of illnesses according to complex processes that will be targeted for new therapies; computer-aided decision-making to integrate multidimensional data in individually-dimensioned probabilistic models; individual prevision that will become possible, also considering the qualitative dimensions of persons who therefore will be more actively involved in diagnostic and therapeutic choices; the production of interdisciplinary models that generate a more interactive model of medicine among practitioners; the initial development and testing of drugs and therapies in silico, both saving time and expanding the potential to identify more effective targets; and the generation of remotely-collected individual patient health data via portable devices that patients can wear.
At a societal level, diagnostic costs may rise. However, savings might still be achieved via the development and use of treatments that are more individual-patient appropriate therefore reducing public expenditure and increasing public health. For this to occur, however, several things must occur, including new models of public-private collaboration; new agreements on drug development; infrastructure changes like the implementation of complex phenotypization stations that should be made available for everyone; the marketing of wearable devices for dynamic phenotypization and constructing large data repositories to allow for broad access to relevant healthcare data; more elastic and adaptive, “glocalistic”, models of public healthcare to monitor the personal histories of patients and promptly respond to varying individual health needs despite similar diseases, by classical definitions; a redefinition of privacy and legal issues considering ethical issues in systemic approaches; a new culture addressing the implications of complexity in medicine; the empowerment of patients and professionals, including relevant changes in healthcare university curricula; and, finally, an overall shift towards systems science epistemology, methods and technologies.