Georgetown Ushers in New Era of Systems-Based Medicine
(This is part 1 of 3 of a series of articles excerpted from "Georgetown Ushers in New Era of Systems-Based Medicine" in the Spring/Summer 2009 issue of Georgetown Medicine Magazine)
“The future of medicine will continue to be evidence-based, but it will also be holistic — it must be based in an understanding of systems and networks.” — Howard J. Federoff, MD, PhD
Howard J. Federoff, MD, PhD, executive vice president for health sciences at Georgetown University Medical Center, is acutely aware of the hurdles facing the introduction of a sweeping new vision for health care, systems medicine. Federoff sees this approach impacting, not only how patient care is delivered, but perhaps even more importantly, how GUMC teaches, conducts research and engages with the community.
He knows that properly conveying the meaning of this approach, to start, and then addressing the various logistical, technological, financial and ethical issues that surround it will be a great challenge. So strongly does he believe in its promise, however, and in Georgetown’s potential to help usher it in, that he is unwavering in his commitment to getting out the word.
“This is the future. It is a question, not really of if it’s going to come, but really when,” Federoff said.
Levels of understanding vary widely as to exactly how this concept will play out – not only at Georgetown, but in many forward-looking academic health centers around the country. But throughout the Medical Center, researchers, faculty and administrators are gearing up to implement this approach.
As a concept, systems medicine is at once complex and straightforward. Federoff, who marked two years at Georgetown in April, describes it as an approach that will allow health care providers to understand the interplay between genetics and the environment in such a way that they will be able to predict who is at greatest risk for disease, rather than simply reacting to symptoms.
“It will allow one, for the first time, to grapple with inherited vulnerability, while understanding within the setting of the environment how that vulnerability is modulated either upwardly or downwardly to produce the longitudinal readout of risk for the major classes of disease,” he said.
The potential health and societal benefits of this approach are innumerable, though still remote.
Perhaps as soon as 20 years from now, the medical checkup will look dramatically different than it does today. A healthy 10-year-old and his parents will sit down as a family to offer a detailed family history to the health care provider.
The provider will question them about all environmental factors that have been shown to impact health, including their activity level, where they live and what types of food they eat. Then the provider will order a series of tests that reflect all the information that has been gleaned in molecular biology, genomics and the interaction of genes and the environment.
“There is an intrinsic value for delivering patient care, because you shift the locus of where health care is currently – treating manifestations of disease often just symptomatically – to being able to dial back the clock to primary prevention,” Federoff said.
Federoff touts a societal benefit as well. Identifying those at high risk for certain diseases or disorders early will reduce their likelihood of developing symptoms that will diminish their contributions to society, he said. These individuals will be more productive and less likely to become reliant on chronic medications and therapies than they would have if their condition had been discovered later.
Mobilization of Forces
To bring this vision to life, Federoff anticipates “an obligate sequence of work to be done” involving a complex synchronization of many moving – and constantly evolving – parts. Through initiatives in education, research and clinical care, the Medical Center is pushing forward a strategy he and others hope will position GUMC at the forefront of the systems medicine movement.
“It’s almost like trying to build the perfect watch. You have an array of pieces, and you know there is a sequence to put them together so you can keep precise time,” Federoff said. “I am not the perfect Swiss watch maker yet, so I am starting with the case, and trying to understand which pieces I need to lay in first, second and third.”
Providing some needed structure to the process is the Medical Center’s ongoing Strategic Planning Initiative (SPI), which began in April 2008. Through its systems medicine design committee, the SPI is mapping out which steps are most important to moving systems medicine forward, especially regarding the types of research conducted and how Georgetown educates its students.
Early this year, the systems medicine group presented its first-phase findings to Federoff and other Medical Center leaders, and it has since moved into the implementation phase. The charge was to analyze the Medical Center’s existing research expertise, infrastructure and clinical practice and to see what changes will need to occur within the medical school to prepare faculty and students to execute systems medicine.
Through this analysis, which lasted nearly a year, the subcommittee found that the Medical Center already has many of the necessary ingredients in place, but much work still remains.
“We have a faculty that is extraordinarily well-positioned and open to applying a systems medicine approach, and we have a scientific community that contains many of the necessary skills and resources to perform the required molecular studies,” said Louis M. Weiner, MD, director of Georgetown’s Lombardi Comprehensive Cancer Center and co-chair of the systems medicine design team.
Yet proving the viability of systems medicine will require establishing that it yields better information than traditional approaches.
“We have to prove it’s worth all the money and the effort. If we can’t show that then we are not ready yet to implement a systems-based approach for general medical care,” Weiner said.
To answer this question, Weiner and colleagues are testing the systems medicine hypothesis in the clinical trial setting, starting with cancer patients. Lombardi researchers have identified common cancers that represent important public health problems, such as breast cancer and colon cancer, isolating “good binary questions we can ask where there is a clean clinical outcome,” Weiner said.
“We can connect such clinical outcomes to the molecular data and use that knowledge to personalize therapy, identify potentially new biomarkers of disease or therapeutic targets, and learn about the pathways and molecules that really matter for a particular disease state,” he said. “We’ll see whether applying the systems medicine approach can satisfactorily answer these types of questions and, if so, I predict we’ll attract significant philanthropic support and grant funding to expand our efforts to encompass more diseases and more people.”
By Lauren Wolkoff, excerpted from the 2009 Spring/Summer issue of Georgetown Medicine Magazine.