CENTRAL DOGMA
 |
| Francis Crick's Central Dogma |
To
guide this essay, I’d like to borrow and idea from Francis Crick. In 1958,
Crick stated the “Central Dogma of Molecular Biology”, which goes something
like this: DNA replicates itself and transcribes information into RNA, and RNA
translates that information into proteins. The terms “transcription” and
“translation” are carefully chosen as they are borrowed from linguistics.
‘Transription” is rewriting something in the same language (DNA and RNA
molecules are made of the same stuff), whereas “translation” involves
converting something from one language to another (from DNA/RNA language into
the language of proteins).
 |
| My own twist |
I’d like to state my own central
dogma of health care. Scientists guide their own research and transcribe their
information for the benefit of health care professionals. I associate this
exchange as “transcription” because scientists and health care professionals
are both fluent in the language of science. That information is then translated
by health care professionals for their patients. I’m associating this exchange
with “translation” because the average guy at a bus stop is most likely not
able to digest a scientific journal article on contemporary molecular genetics.
TRANSCRIPTION:
SCIENTISTS TO HEALTH CARE PROFESSIONALS
It is no stretch of the imagination
to suppose that the world of medicine will be improved greatly as our
understanding of genetics improves. It is possible that reviewing our genetic
sequence will become a part of regular checkups within 10 years – certainly
within 25 years. People are already having their DNA fully sequenced in
anticipation of this, and it is getting cheaper to do so all the time. The National
Human Genome Research Institute set goals to cut the cost to sequence an
individual’s DNA to $100,000 by 2009 and to $1,000 by 2014 (and it seems we are
ahead of schedule). It won’t be long before having your DNA sequenced will be
as routine as having a blood test. It has been a long time since there has been
such a big change in health care. I think it is fair to say that the
forthcoming impact of genetic information on such a huge number of issues in
health care will be the most dramatic revolution in the history of medicine.
None
of this is particularly Earth-shattering, even if it sounds good to make predictions
like this in my grade 12 biology classes.
TRANSLATION:
SCIENTISTS TO DOCTORS
Understandably,
there has always been a significant discrepancy in knowledge between doctors
and patients. Studies are conducted on an ongoing basis on this discrepancy and
how effectively the gap is bridged by doctors. Even at this stage in history,
this is an important issue that significantly affects the practice of medicine.
However,
bringing genetics into this adds a much greater complexity of information to the
doctor-patient dynamic. As it stands, the average patient knows their body and
can learn more about whatever part is bothering them. They understand
information about blood, diet, exercise, surgery, pharmacy and physical
therapy, and could probably recognize many internal organs by sight. However,
the vernacular of genetics is not common knowledge and may not even be
something that many patients can read up on in order to come to grips with what
is going on in their treatment.
As
a high school biology teacher, I have a decent idea of what people know (and
don’t know) about science in general, and genetics in particular. Where I live
(in Ontario, Canada), students are only required to learn about science through
grade 10. In that time, they learn almost nothing about genetics. High school
graduates who take the minimum amount of science in high school will only be
able to tell you that chromosomes contain genetic information and are the
blueprint for the cell, and that they are copied during cell division. That said,
many students go on to take biology in grade 11, so they will be exposed to
Mendelian genetics and a basic overview of the construction of the DNA molecule
(there are four bases, and how complementary base-pairing works). For the
significantly fewer number of students who take “university preparation”
biology in grade 12, they get a far greater exposure to molecular genetics. In
my experience, I would say only about half of these students actually “get it”,
though they are certainly exposed to a lot of information.
LOST IN
TRANSLATION
This
brings us to my prediction. The discrepancy in knowledge between doctors and
patients – already a big issue – will become a full-fledged crisis in patient
care as genetics becomes central to health care. The title of this article –
The Translation Gap – refers to this enormous discrepancy in knowledge and all
of the issues that arise from it.
As
it stands, there is no age group of society that is well-prepared with the
rudimentary knowledge necessary to process medical treatment that is centered
upon their genetic makeup. Consider…
** Elderly patients were born before
mankind recognized DNA as hereditary material. In most cases, these people probably
know almost nothing about genetics
** Patients of the “Baby Boom” generation,
despite having grown up in a world where DNA was better understood, are also
unlikely to have more than a superficial knowledge of genetics
** Patients born in the neighborhood
of 1960 – 1980 would generally know a bit more about genetics, but probably not
much more than what is revealed in the average prime-time television criminal/forensics
drama series.
** The current “youth” (people born
1990 – present) are not learning much about genetics either.
** Without significant changes to
the science curriculum moving forward, the education system will continue to
produce citizens with very limited knowledge of genetics.
I
should also mention what I regard as a smaller, though not insignificant issue.
I feel it is fair to wonder whether or not we will also experience somewhat of
a breakdown in the ‘transcription’ of information. Health care professionals
have varying levels of familiarity with developments in genetics. In the coming
years, all of them will be expected to operate with an enormous amount of new
information. Will there be sufficient professional development available to
physicians everywhere to make appropriate use of all the new knowledge? I feel
this is probably a smaller issue due to the fact that health care professionals
are sufficiently intelligent and responsible enough to acquire the information
they need to perform their duties. In addition, the availability of other
health care professionals for second opinions mitigates the risk of serious
errors affecting patient care.
FALLOUT
What
can we expect as a result of the Translation Gap? To be sure, the effects will
be far-reaching, and it is probably beyond my limited mental fortitude to
foresee them all. However, a few notions occur to me.
** Folks with a solid knowledge base
in genetics will be valuable in society. Genetic consulting – perhaps by
paramedical staff – may become a widespread industry. Education and outreach
programs will become an even larger and more significant part of the operation
of hospitals, clinics and educational institutions.
** Many patients will fall into
extremes in response to the new medicine.
** At one extreme, despair may
become a significant issue. Already there are reports of patients committing
suicide upon learning that their genetic makeup predicts future health concerns
(even though their makeup most likely indicates a chance of future concerns
rather than a guarantee). The new developments in medicine promise to be of
tremendous use, but medicine as we know it today will be far from obsolete and
the new developments will have limitations that may not be appreciated by lay
people.
** At the other extreme, there may
be a significant portion of society that doubts the ability of the new
technology. This would be like the resistance to the knowledge that smoking
dramatically increases the likelihood of lung cancer. In the early days, it was
more common for people to dismiss the connection due to the fact that
“increased likelihood” is not the same as “guarantee” and there have always
been exceptions (folks who smoked into their 90s having never gotten lung
cancer). By comparison, smoking is still being marginalized 50 years after the
Surgeon General’s report. If you prefer a more modern example, look how
resistant the general public is the human-caused climate change. This will be
exacerbated by the fact that genetics will often indicate a “likelihood” (not a
guarantee) of health issues, and there will be ample instances of patients who
did not get the condition for which they were genetically predisposed.
** Doctor-patient relationships are
strained as it becomes harder and harder for the patient to understand what
their doctor is talking about.
** Money, money, money. There will
be tons of it to be made. Biotech companies, particularly those involved in
genetic/forensic equipment, should do great. Pharmaceuticals may well have to
reinvent themselves. Also, there will be plenty of snake-oil type operations,
peddling nonsense as elixir.
** There will be many new areas of
ethics under consideration. Sure, sure, we already have a lot of ethics issues
surrounding genetics, but the new knowledge will almost certainly open issues
that either haven’t been thought of, or at the very least haven’t received as
much attention as necessary.
** The Wild West? Like the internet of
the 1990s, there may be a phase where new knowledge and technologies become
available faster than we (as humans) will know how to sort it all out in proper
ways. The world will not slow down, though, so there will be many pioneering
cases of new knowledge setting precedents that affect generations to come,
especially in the early days. It could take a few decades to iron out all the
details in a meaningful way (and, of course, there will be wrinkles upon
wrinkles in the fabric of health care as the process evolves).
KNOWLEDGE IS
POWER
Perhaps
I have misfired on some of the shrapnel that the Translation Gap will create.
However, I do not doubt that genetics will cause a revolution in practical
medicine, and I do not doubt that the average patient will have little idea
what it all means. Interestingly, improvements to technology have allowed
mankind this great leap forward, but how well we respond to it will largely
depend on the social abilities of health care professionals and patients alike.
From
my point of view, there are two appropriate responses. One is to learn some
genetics. You have some time, but you definitely want in on this medical
revolution and the sooner the better. This is definitely a case where knowledge
for the sake of knowledge now will bear significant fruit later. The second appropriate
response is to talk to people about it. Talk to everyone about it; your doctor,
your friends who are doctors, your friends, your teachers, your families, your
colleagues…everyone. The two points are
related, of course – If you have a solid understanding of genetics, you will be
of use to your elderly uncle if he develops a condition which has a new
treatment.
Really,
the crisis I predict here should not actually happen, because it is absolutely
no mystery that the revolution is coming. If my estimates above are correct, we
probably have a decade or two to get everyone wise. That should be enough time.
In the long run, the world will adapt to this knowledge. However, if this crisis
occurs, it will cause a great deal of heartache (not to mention losses of money
and progress) that should have been avoided.
Color
me skeptical, though. I mentioned climate change earlier, which is another
instance of a problem that we know is coming, that we understand very well, and
that humankind is not addressing in a meaningful way. I fully expect this issue
to hit us like we never saw it coming. It would be nice to be wrong on this
one, but I doubt if I am.
