References

In the first few years of the 21st century, a climber more than 65 years old will stand on the summit of Mount Everest. Absurd as such an idea might have seemed 25 years ago, mountaineers are now so sure it will happen that they speculate about who it will be, not if it will be.

The image of an exultant senior citizen atop the highest peak in the world points up the changing perceptions of age in industrialized societies. Americans now expect to compete at sports, to be sexually vigorous, to bear children and to raise families at a much older age than ever before. It's been said that the current generation of younger Americans isn't just trying to hold off the ravages of age--it expects to.

These new expectations could profoundly change future medical practice. Throughout the 20th century, medicine has advanced primarily by improving curative care: intensive-care units, bypass and transplant surgery, antibiotics and chemotherapy. But curative care has its limits, and nothing makes that clearer than the image of a 65-year-old atop Everest, or a 45- year-old woman bearing down in childbirth or a 50-year-old astronaut. To maintain a high level of fitness we must avoid physical decline, not repair it: open-heart surgery, even at its most effective, will never make you as good as new, especially if you intend to climb mountains. And for the major killers of American society--heart disease and cancer--the most effective preventive measures involve changes in lifestyle.

The physician as lifestyle expert, as wellness adviser, has already begun to appear. And as genetic profiles and other predictive tools improve, the art of prevention will grow far more sophisticated. Physicians will administer tests and, armed with the results, prescribe preventive measures just as precisely as they now dispense medications.

Advances in medical technology will also extend the current trend toward noninvasive diagnostic procedures, such as nuclear magnetic resonance imaging and ultrasound. Treatment will change along similar lines. Surgery will be less common and hospitalization much rarer. As patients, we will expect more procedures to be done quickly, painlessly (and inexpensively) on an outpatient basis. Microtechnology will revolutionize medicine with futuristic devices, ranging from biosensors that dispense drugs under the skin to nanomachines, hardly larger than red blood cells, that course through our bloodstream scrubbing the insides of our arteries.

Even more fundamental will be gene-replacement therapy, in which missing or defective genes are supplied by the physician. Such procedures are being developed to treat serious illness, but they will eventually be used to boost enzyme levels and hormone production to retard aging and to increase vigor.

Accompanying the use of more refined technology to prevent and treat illness, psychoimmunology, the science that deals with the mind's role in helping the immune system to fight disease, will become a vitally important clinical field--perhaps the most important medical field in the 21st century-- supplanting our present emphasis on oncology and cardiology. Healthy thinking may eventually become an integral aspect of treatment for everything from allergies to liver transplants.

What all this means is that our present concept of medicine will disappear. Pressed both by patients and its own advancing technology, medicine will change its focus from treatment to enhancement, from repair to improvement, from diminished sickness to increased performance. That transformation has already begun. It will reach its logical conclusion when the first 65-year-old stands atop Mount Everest, and the relationship of humanity and medicine enters a new and extraordinary era.

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