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The Future of Medicine

Eric Topol, MD, has written a book about the convergence of the digital revolution and medicine. It is full of fascinating information and prognostication, but I wish he had given it a better title.  He called it The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health Care. Medicine will not and cannot be “destroyed.” It will be improved and transformed, perhaps, but not destroyed. And any new developments will have to be evaluated for safety and effectiveness by the good old time-tested methods of science.

The future world of medicine is really exciting: science fiction is becoming real. As I read Topol’s  book I serendipitously found it paraphrased by a character in another book I was reading, Chop Shop, by Tim Downs.

I see a world where no one ever dies from an adverse drug reaction; where physicians have an entire range of medicines to choose from to treat a deadly disease; where medications target tumors like smart bombs and leave surrounding tissues unharmed; where genetic susceptibility to disease can be determined in childhood, and possibly even prevented.

(If you haven’t yet discovered Downs’ hilarious “Bug Man” detective series about a crazy forensic entomologist, you have a treat in store.)

But back to non-fiction. Our world is changing almost too rapidly to comprehend: the Internet reaches everywhere, and there are far more mobile phones in the world today than toilets.  We have hardly begun to tap the current potential of new technologies, and unimagined further developments await us. Topol is a qualified guide to this new world: he is a respected cardiologist and geneticist who ha s been on the forefront of wireless medicine and who was a major whistleblower in the Vioxx fiasco. He knows whereof he speaks, and he writes lucidly and accessibly.

Monitoring. Sensors now available or in development can do amazing things. They can monitor chronic diseases and provide remote electronic early warning of medical crises. Biosensors in cars could prevent accidents by detecting impending seizures, heart attacks, diabetic reactions, etc. Monitoring is a good thing, but you can have too much of a good thing, and some of what Topol advocates smacks of overkill. One of his patients sends him e-mails with 3 or 4 daily measurements of everything from blood pressure to oxygen saturation. Topol monitors his own sleep witha Zeo device.  This is “nice to know” information but its impact on health outcomes is not so clear.

Lab on a Chip. A biosensor can be incorporated into a cell phone’s SIM card to do everything from detecting malaria to analyzing electrolytes. A phone camera can take a picture of a skin lesion and use a sophisticated algorithm to determine if it is melanoma. Digitizing breath might detect lung cancer. A high-tech “tattoo” worn on the skin can be read by your cell phone to measure your blood sugar.

The Office Visit of the Future. Virtual office visits may replace face-to-face encounters. Tools like video chats, telemedicine, and e-mail are already available.

Electronic Health Records as a Research Platform. Electronic databases have enormous potential: they can be useful in drug development, post-marketing surveillance, gathering statistics about disease, and monitoring adequacy of treatment.  Just one example: if every patient on a drug were entered into a single database along with comparable patients not on the drug, even a rare adverse effect could be detected, and less rare effects could be spotted earlier. If we could include DNA sequencing in that database, we might learn which genotypes were susceptible to a certain side effect and could avoid prescribing the drug to such patients. We have the capability to do this today, although implementing it would be far from easy.

The Privacy Issue. Hacking into databases is a danger to patient privacy today, and the danger will grow in proportion to the amount and value of the data. No one has yet built a truly hack-proof system, and it’s unclear that if it will ever be truly possible. As with medicine itself, the benefits must outweigh the risks. But consider what it would be worth to the large insurance companies and employers of the future, if they could discriminate based on genetic profiles and other private medical information.

Genomics. Our ability to sequence patients’ genomes opens up whole new worlds. Topol characterizes genome analysis as “hypothesis-free” research, but I don’t think that’s quite accurate. We can screen lots of data looking for the unexpected, but we are still working with hypotheses about how that screening can produce results. Topol is enthusiastic about currently available direct-to-consumer genetic testing; I’m not so sanguine. He says if his genome showed a high risk of blood clots he would be more inclined to get up and walk around on long flights. Maybe. Does genomic testing really change behavior? At least one study showed it didn’t, but Topol was impressed that these patients expressed an increase in the intent to undergo screening tests like colonoscopy. I think supervision and interpretation of these tests by doctors is a reasonable precaution; Topol thinks it would constitute unfair interference with health freedom.

Genetic analyses can assist in drug development by teasing out who benefits and who gets rare side effects. With knowledge of gene specific effects, some rejected drugs might have been approved for a subset of patients.

Topol recognizes that it will not be a simple matter of finding a gene for every disease. Genetics is far more complicated: many conditions are multifactorial, genes interact with each other, and environmental factors affect gene expression. David Gorski’s recent article explains the complexity of genetic factors in cancer.  In one study he cites, multiple biopsy samples revealed different genetic profiles in different parts of the primary tumor and metastases. Personalized treatment based on genetic analysis of a single biopsy would fail.

The Nicholas Volker Case. Topol describes this as the first instance of the life-saving power of genomic medicine. A child with a unique bowel disorder was found to have a mutation and was treated with an umbilical cord blood stem cell transfusion. His recovery was attributed to DNA sequencing, but doctors had already been contemplating this stem cell treatment before the mutation was detected. The outcome might have been the same without DNA testing.

Treating the Individual.  CAM providers claim to tailor their treatments to the individual, but they are mainly making things up or relying on pseudoscience. In the medicine of the future, we will have truly individualized treatment based on scientific reality.

Doctor Bashing Topol criticizes current medical practice for relying too heavily on randomized trials and using population-based rather than individualized treatments. He speaks of “Resistance from the priesthood of medicine.” He says “Of all the professions represented on the planet, perhaps none is more resistant to change than physicians.”

I think that’s demonstrably false. Medical practice is constantly changing and evolving in response to new information and new technologies. It is true that it takes an average of 17 years from medical discovery to daily clinical practice and that this can be accelerated. We can do better. But so far there are very few instances where we have the knowledge to tailor prescriptions to a patient’s genome, and treatments based on studies of large groups are surely better than guesswork.

CAM

He quotes a review in The Economist that concluded “Virtually all alternative medicine is bunk” and characterized the CAM industry as a placebo-delivery service. I don’t disagree with that.  But Topol is careless about specific CAM facts. Some of his errors:

  •  “To date, the only randomized, rigorously performed trial of a supplement was of glucosamine’s effect on knee arthritis.”
  • Glucosamine is “quite effective.”
  • His description of Simon Singh’s book and legal troubles is inaccurate on several counts.
  • He claims that acupuncture, hypnosis and guided imagery lead to better outcomes, and that this is supported by good studies.

I noticed this amusing typo: “Chronic disease…[affects] more than 140 individuals in the United States.” Right, a lot more!

Cautious Optimism

The future of medicine holds great promise. I don’t mean to be a wet blanket, but the challenge will be to temper our enthusiasm with good judgment. We can’t assume unalloyed benefit from every technological advance. Just because we can do something like constantly telemonitoring everything from our serum potassium level to our blood pressure doesn’t mean we should do it, or that it would be a good use of limited health care funds.  We don’t want to create a world of cyberchondriacs. Data overload is a problem. Privacy is a major concern. Forgoing face-to-face human interaction may have significant downsides. What’s called for is what scientific medicine has always called for: cautious enthusiasm with scientific testing. Not “the destruction of medicine,” but the natural continuation of it.

Posted in: Book & movie reviews, Science and Medicine

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21 thoughts on “The Future of Medicine

  1. windriven says:

    “[B]ut I wish he had given it a better title. He called it The Creative Destruction of Medicine: How the Digital Revolution Will Create Better Health Care.”

    I suspect that Topol used ‘creative destruction’ in the sense that economists use it: the process of inefficient activities being replaced by more useful ones. In economics the usual example is buggy whip makers in the age of automobiles. In medicine it might be blood-letting in the age of vancomycin. Just as it is not economies that are destroyed – only inefficient or inappropriate employment of capital, it is not medicine that will be destroyed – only inefficient or ineffective diagnostic and therapeutic tools.

    See “Capitalism, Socialism, and Democracy”, Joseph Schumpeter, 1942

  2. rork says:

    “In the medicine of the future, we will have truly individualized treatment based on scientific reality.”

    Hope this isn’t just quibbling about definitions.
    I’m skeptical, but maybe I am not sure what the author intends. Varmus has given the warnings about saying what you mean when you say individualized, cause you probably don’t mean individualized. Maybe it means “more nearly individualized”, but that’s not what gets said, and even that would be fuzzy.

    Ever more highly stratified treatment of patients is what I hope for. (Sounds so boring doesn’t it?) Otherwise, how can we demonstrate efficacy for individuals?
    Say I’ve got some crazy (or not) decision rule for treatments, and compare it to another crazy decision rule, and find the first beats the second on average. For new patient, all I can give for evidence is that on average first rule was better. Perhaps for people like them it might be much worse, but it was much better for a different kind of patient. Will you tell that to your patients? Is that the medicine we dream of?
    If we instead chop patients into groups, we can at least ask if first rule beat second rule within any particular group. Does it take allot of data? Yes.

    Maybe I’m wrong. Maybe we will be acting based on average outcome of a decision rule, mostly for lack of time and data to figure it out better. I’m uncomfortable with that, even though I know that a winning decision rule has “better expected outcome” in the technical sense. If we don’t stratify, how can we come up with improved versions of the decision rule, except by making them up and trying every one of them?

  3. fledarmus1 says:

    “Monitoring. Sensors now available or in development can do amazing things. They can monitor chronic diseases and provide remote electronic early warning of medical crises. Biosensors in cars could prevent accidents by detecting impending seizures, heart attacks, diabetic reactions, etc. ”

    My guess is that long before that, they will be used to detect such things as intoxicated drivers, the use of illegal drugs, the presence of cigarette smoke in unauthorized areas; and that the use or threat of use of this type of monitoring by aggressive law enforcement, litigious organizations and individuals, papparazzi, or political hit-men will make it as unpopular as GPS tracking of cell-phones and automobiles. Constant motoring can be a wonderful thing, but once it is present it will also be an extremely intrusive form of surveillance available to everyone from security agencies to divorce lawyers.

  4. qetzal says:

    @Rork

    When people talk about ‘truly individualized treatments,’ I think there’s often an assumption that we’ll understand so much that we’ll be able to anticipate how each treatment will work for each patient, based on their genetics, history, conditions, etc. Under that sort of assumption, clinical trials and increased stratification would become mostly unnecessary. We’d just be so darn smart and knowledable that it would be obvious that Drug X was best for Patient W, even without direct clinical evidence.

    At least, that’s the impression I get from some of these futuristic predictions. Otherwise, it would be as you said: simply greater stratification during clinical study.

    Personally, I think anyone who believes we’ll learn that much anytime soon is being very naive. But I’ll be happy to be proven wrong!

  5. Harriet Hall says:

    By “truly individualized medicine” I don’t mean better stratification or total understanding. I mean adjusting treatments in response to individual characteristics that we understand: things like reducing the dose of a specific drug because the patient’s genome tells us he lacks the enzyme necessary to metabolize it.

  6. cervantes says:

    There’s a pervasive cultural bias to overhype medical advances. I’m not sure why that is but we are constantly seeing one or another interesting preliminary result in mice presented as the philosopher’s stone. And then once some treatment or test does make it through clinical trials (inevitably much more limited in applicability and effect than the ten year old hype from the mouse study), we overuse it. We just seem to be condemned to this routine.

  7. cervantes says:

    And right on cue, today’s “JAMA 100 years ago”:

    Unfortunately advances in scientific medicine are frequently heralded as being of much more value and importance than they can possibly prove to be. Sometimes this is due to the desire of the newspaper reporter to make a good story, but it is occasionally suspected that medical men are not wholly innocent in the matter. W. M. Barton1 analyzes the cause of this tendency: Men who are deeply thoughtful, thorough students appreciate the relative importance of new discoveries, and in the majority of instances thc charge of exaggerating the importance and effect of their work cannot be sustained against them. “The very difficulty of carrying into execution the simplest principles of their science teaches them a demeanor of conservatism and humility. But to the dilettante or amateur in hygiene nothing is impossible in sanitary science.” No human plague exists which cannot be scientifically eradicated if only the rules proposed by these neophytes are followed. Barton further points out that the public loses confidence in medical science, after finding that some of these heralded improvements accomplish far less than was promised. The thoroughly cultivated, scientific man is conservative concerning the significance of a new discovery. His experience has taught him to hesitate to make emphatic statements. He may not interest the public so much at the moment, but his wisdom and reputation will last longer.

    1. Barton, W. M.: Washington Med. Ann., January, 1912, p. 314.

    JAMA. 1912;58(15):1120-1121

  8. qetzal says:

    But Dr. Hall, don’t we already have that kind of ‘truly individualized treatment?” Obviously we’re limited by our current knowledge, but that will always be the case. Are you suggesting something will be qualitatively different in the forseeable future? Or are you merely suggesting a quantitaive improvment – doing more of what we already do, based on greater knowledge?

    If the latter, I agree with you. But these futurist predictions always sound to me like they’re describing some fundamental leap. I think that’s part of what Rork was questioning as well.

  9. cervantes says:

    qetzal, the classic method of evaluating medical interventions — the randomized controlled trial — does a very poor job of discriminating between who will benefit from treatments and those for whom they may be less appropriate. There is a major movement underway in medical research to improve on this, through innovative trial designs and new methods for observational research. This is a very long story, to say the least. You’re right, don’t expect a sudden, fundamental change, but do hope for progress over time.

  10. BobbyG says:

    @# qetzalon 17 Apr 2012 at 2:04 pm

    But Dr. Hall, don’t we already have that kind of ‘truly individualized treatment?” Obviously we’re limited by our current knowledge, but that will always be the case. Are you suggesting something will be qualitatively different in the forseeable future? Or are you merely suggesting a quantitaive improvment – doing more of what we already do, based on greater knowledge?
    __

    See “Medicine in Denial,” Lawrence Weed, MD and Lincoln Weed, PhD

    e.g.-

    FORWARD

    Essential to health care reform are two elements: standards of care for managing clinical information (analogous to accounting standards for managing financial information), and electronic tools designed to implement those standards. Both elements are external to the physician’s mind. Although in large part already developed, these elements are virtually absent from health care. Without these elements, the physician continues to be relied upon as a repository of knowledge and a vehicle for information processing. The resulting disorder blocks health information technology from realizing its enormous potential, and deprives health care reform of an essential foundation. In contrast, standards and tools designed to integrate detailed patient data with comprehensive medical knowledge make it possible to define the data and knowledge taken into account for decision making. Similarly, standards for organizing patient data over time in medical records make it possible to trace connections among the data collected, the patient’s problems, the practitioner’s assessments, the actions taken, the patient’s progress, the patient’s behaviors and ultimate outcomes.

    Two basic standards of care, and corresponding tools, bring order and transparency to medical decision making:

    • First, from the outset of care, relevant patient data must be chosen, and its implications determined, based on the best available medical knowledge, independent of the limited personal knowledge of the practitioners involved. Patient data must be systematically linked to medical knowledge in a combinatorial manner, before the exercise of clinical judgment, using information tools to elicit all possibilities relevant to the problem situation, while defining and documenting the information taken into account. Practitioners’ clinical judgments may add to, but must not subtract from, high standards of accuracy, completeness and objectivity for that information.

    • Second, in complex cases, particularly in cases of chronic disease, the organization of data in medical records must be optimized for managing multiple problems over time. This means that each medical record must begin with a complete list of carefully defined patient problems, and that other clinical information in the record must be linked to the problem or problems to which it relates. Without that structure for the medical record, decisions are made out of context, follow-up and coordination of care are haphazard, and records are not usable for rigorous clinical research.

    With these two basic standards of care, and the information tools needed to implement them, practitioners and patients can manage the flood of detailed information required for sound decision making over time. With this detailed information, made usable for research in structured electronic medical records, medical care can become increasingly refined and individualized. In contrast, so-called “evidence-based medicine” is derived from large population studies that fail to account for the medical uniqueness of each patient.

    Enforcing the necessary standards and tools depends on changing medicine’s culture of professional autonomy for highly educated physicians. Indeed, the concept of a physician as we know it is not viable. All practitioners must submit to meticulous definition and control of their inputs to care (a principle recognized by the patient safety movement). The primary barrier to this cultural change is graduate medical education and credentialing. These social institutions (1) fail to define, disseminate and enforce high standards of quality for provider inputs to care, (2) inhibit effective design and use of information technology to manage clinical information, and (3) suppress competition among providers who might otherwise exploit information technology to generate remarkable advances in patient care and medical knowledge.
    __

    266 pages of interesting stuff.

  11. Harriet Hall says:

    @qetzal,
    ” don’t we already have that kind of ‘truly individualized treatment?”

    Only in a few limited circumstances. Pharmacogenetics is in its infancy. At present we have only a few facts to guide us; in future we can expect a flood of data with whole new orders of magnitude. And we can only guess what different kinds of genomic and other knowledge might guide individualized treatments down the road.

  12. David Gorski says:

    By “truly individualized medicine” I don’t mean better stratification or total understanding. I mean adjusting treatments in response to individual characteristics that we understand: things like reducing the dose of a specific drug because the patient’s genome tells us he lacks the enzyme necessary to metabolize it.

    As I think I’ve mentioned before in various posts I’ve done on the topic, I really don’t like the term “personalized medicine.” It’s turned into far more of a buzzword than anything else. Also, I think it’s really a stretch to think that we’re anywhere near close enough to understanding enough about genomics, proteomics, and metabolomics to deliver on the promise of something called “personalized medicine.” That’s why I now rather prefer the term “stratified medicine.”

  13. DugganSC says:

    Regarding databases, it’s not all about unauthorized access. Many people also fear that the joining of databases will lead to insurance providers barring from coverage people with certain genetic predispositions, or massively increasing their premium. This can be exacerbated by the fact that, as mentioned earlier in the comments, the mechanism of the genes isn’t always well understood, even by the doctors and the medical experts hired by the insurance companies, let alone CEOs who just read something in Time magazine about one gene determining whether you get cancer. Moreover, databases often lead to issues of data permanency, particularly bad data. To give an example, my mother came up with a positive on a Hepatitis test a good decade ago. Despite multiple tests showing that the one test was a false positive, she’s still on the Do not Donate list for blood. Imagine that, instead, one of the overseas data entry people confused your records for someone with the same name who has a terminal disease. How many times will you get rejected for insurance because the company database shows you have a pre-existing condition?

    Regarding doctors changing… medicine changes rapidly, but most of the doctors I know are either early adopters who want to try the new techniques as soon as they come out, sometimes before they’re properly tested (a lot of the ones advocating CAM treatments fall under this, of course) or firmly fixated on how they learned it back in med school, not wanting to mess with what works unless they absolutely have to.

    Incidentally, good point, fledermus1, on how the use of sensors for medical issues will be hampered by bad press from it being used for other purposes.

  14. pmoran says:

    As I think I’ve mentioned before in various posts I’ve done on the topic, I really don’t like the term “personalized medicine.” It’s turned into far more of a buzzword than anything else. Also, I think it’s really a stretch to think that we’re anywhere near close enough to understanding enough about genomics, proteomics, and metabolomics to deliver on the promise of something called “personalized medicine.” That’s why I now rather prefer the term “stratified medicine.”

    Yes. Nice idea, personalised medicine, but for practical purposes we will always be dealing with patient sub-groups, not individual persons. It is also inconceivable that if the evidence is there and the capability is provided to us (often an economic matter) we would not adopt anything that significantly improves outcomes for identifiable sub-populations.

    The “everyone is unique” notion appeals to to some, but a little thought reveals that it undermines the whole concept of ,medicine as a system of knowledge. You would be unable to say anything about the NEXT patient from anything that went on before..

  15. BobbyG says:

    @# DugganSCon 17 Apr 2012 at 4:47 pm

    “Regarding databases, it’s not all about unauthorized access. Many people also fear that the joining of databases will lead to insurance providers barring from coverage people with certain genetic predispositions, or massively increasing their premium.”
    ___

    Kick the for-profit actuarial risk model to the sidelines. Problem largely solved (see “The Moral Hazard Myth”).

    Not that there won’t be other discrimination problems resulting from data mining. But, with the exponentially increased availability of health/medical information, we will all be come “uninsurable” from a profit perspective eventually. We’re all “at risk” for one thing or another regarding which underwriters would say “no thanks, we’ll pass.”

    I think people would be rather unpleasantly shocked to know the extent to which our every move on the internet (e.g., Google, “social media”) is being recorded and aggregated and mined and modeled and bundled and sold (all outside the putative regulatory regimes).

    “Your Permanent Record.” Remember that, when you got sent to detention in grade school, and you got threatened with that?

    :)

  16. Harriet Hall says:

    I don’t envision “individualized” medicine as “everyone is unique.” To me it means simply taking into account any information we have about the individual, such as a SNP affecting drug metabolism or what other drugs they are already taking, rather than using a simplistic “one drug/one dose” treatment on everyone. Ironically, the CAM folks who claim to offer individualized treatment often restrict themselves to one kind of tool (acupuncture needles, diluted remedies, manipulations, etc.) They may try to apply that tool differently to different patients, but they don’t have any real evidence to guide them.

  17. qetzal says:

    Dr. Hall:

    Pharmacogenetics is in its infancy. At present we have only a few facts to guide us; in future we can expect a flood of data with whole new orders of magnitude. And we can only guess what different kinds of genomic and other knowledge might guide individualized treatments down the road.

    I agree we’ll have more to guide us. I just don’t see it being qualitatively different from what we do now. It will still be stratification, just at finer levels. And it will still require clinical validation in almost every case. Beyond that, I don’t think we can confidently predict fundamental changes. Especially if we can only guess what knowledge will supposedly guide us.

  18. Harriet Hall says:

    @qetzal,

    “I just don’t see it being qualitatively different from what we do now.”

    I agree. In fact, that was the whole point of my post: that medicine will not be destroyed or re-invented, but will simply continue following the best science available, as it has always tried to do.

  19. JMB says:

    “• First, from the outset of care, relevant patient data must be chosen, and its implications determined, based on the best available medical knowledge, independent of the limited personal knowledge of the practitioners involved. Patient data must be systematically linked to medical knowledge in a combinatorial manner, before the exercise of clinical judgment, using information tools to elicit all possibilities relevant to the problem situation, while defining and documenting the information taken into account. Practitioners’ clinical judgments may add to, but must not subtract from, high standards of accuracy, completeness and objectivity for that information.”

    I used to do research in computer aided medical decision making. The problem lies in trying to force the healthcare system to incorporate a poorly conceived system to acquire/record the data. There is a significant cost in efficiency of delivery of care when healthcare providers are held responsible for the coding of the data. Nurses on hospital floors spend over half of their time now entering data on computers. Doctors aren’t too far behind. I have seen the nature of the data recorded, and I known that the value of the data in discriminant functions for computerized decision support will be very limited. The are a few specific health problems that have received much scrutiny in research in which a decision support system could measurably improve the outcomes. Of course, now they have moved the goalposts from outcomes to intermediate “indicators”. That’s a trick in the meaningful use requirements of computerized medical records.

    Instead of spending billions of dollars on forcing the greater use of electronic medical records, and on the roll out of finer grain coding in ICD10, they ought to fund research in how to make the delivery of healthcare more efficient and accurate through the design of EMRs. Anybody who has been forced to use basic search functions in EMRs knows that those search functions are lousy compared to what we have available for internet search engines. Relational database, or btrieve models may be necessary for billing functions, but they are very inefficient when recording medical decisions and hourly outcomes. Their needs to be significant improvement in the healthcare providers ability to retrieve the historical data. The needs to be further improvement in the ways to summarize the data.

    After they make EMR’s that will not force our attention away from the patient, then they can talk about universal adoption.

    Least you think I am anti technology, I actually advocated the use of coding in mammogram reports to establish a national database. However, I worked hard to design a computer interface that made the doctors work more efficient. It seems to me that the knowledge gained in the past about information technology supporting medical decisions is being ignored. It is hard to design a system that will improve the accuracy of the decisions made by the average healthcare provider. Decision support based on expert systems rarely will improve on the decisions. Discriminant functions usually require a lot of data to improve the decisions made by the average healthcare provider. Subjective data used in discriminant functions require some criteria to account for observer dependence.

    Patients will be unhappy to sit there with a doctor paying more attention to their computer screen than to the patient. Don’t make the healthcare provider a bureaucrat.

  20. daedalus2u says:

    I agree with JMB that facilitating the use of existing knowledge and procedures will do more in the short term (and probably long term) than any of these big science top-down projects. But helping the little people who are working in the trenches do their job incrementally better isn’t the transformative advancement that leads to the hero worship that motivates people.

    I think that humans tend to look for big science top-down projects because of human hyperactive agency detection. Humans are always looking for a top-down agent that is causing things to happen, so humans tend to think that a top-down agent is the thing that does make things happen, even if it hasn’t been detected yet.

    Control and power in a social hierarchy comes from the top-down. Scientific progress only comes from the bottom-up. I think this human hyperactive agency detection is what is driving a lot of the hype over scientific progress. I think the implicit feeling is that there must be some top-down control system that is controlling everything, so once we figure it out and can tweek it, then we can be as gods.

    Everyone wants to be the mythic hero who steals fire from the gods so they can take their rightful place as the most important person in the world. Main stream science writers may not understand the science, but they do understand the passion and drive that motivates the scientists they interview for their reports. Those science writers do see the passion and drive and report on it. We who see it second hand can recognize it as the hype that it is, but it is very difficult to have that kind of objectivity when you are the one doing the work. This is something I have personal experience on. ;)

    The problem is that there is no top-down control system in physiology, but that doesn’t keep people from feeling that there is one. At once they attributed it to élan vital and later to homeostasis and now the top-down control system is thought to be hidden somewhere in the genome.

    The behaviors and properties observed in physiology are all emergent properties of the tissue compartments, cells, DNA, and other stuff that comprises organisms. It is exactly analogous to the mind being the emergent property of the brain. There is no top-down control of the brain by the mind, there is only the behavior that we call “the mind” which is an emergent property of the brain.

  21. Donna B. says:

    Thank you! Book recommendations aren’t the reason I read here regularly, but I am enjoying Tim Downs’ books very very much.

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