Innovation in Medicine: Where Does It Come From?
I started to write a note on a recent article about Linus Pauling and realized it needed a preface. Linus was one of my mentors and he had a distinctively different view of medicine than the average physician. He was probably the smartest and most knowledgeable person I have ever worked with and was really bent out of shape because he shared some of his data on DNA structure with Watson and Crick and they got the Nobel Prize. He, of course, already was the only person on the planet who had singlehandedly received two Noble Prizes, but he felt strongly he deserved a third for discovering the structure of DNA. I could never figure out whether this was a character flaw or whether he was right. He was right about most things.
Linus used the scientific method to innovate and break new ground. Most work in science is reworking old ground and making minor improvements. Doing a major overhaul of any scientific theory is risky. When you stick your neck out, you take a lot of flak, and Dr. Pauling was very controversial, particularly among the medical profession.
“Part of the scientific method is that the investigator be willing to accept all the facts. He must not be prejudiced; prejudice might keep him from giving proper consideration to some of the facts or to some of the logical arguments involved in applying the scientific method, and in this way keep him from getting the right answer. If you were to say, “I’ve made up my mind, don’t confuse me with a lot of facts,” you would not be applying the scientific method.” Linus Pauling
Quite often I share some data with another scientist or engineer and the response is, “That is so out of the conventional context of scientific thinking, how could it possibly be true?”
Facts are facts and people regularly ignore, dismiss, or suppress pieces of data that do not fit in to their preconceived notions. Thinking is useful to discover patterns in facts, which can then be used to infer the result of future experiments, i.e. predict future facts. Thinking is useless to science if it is illusion, and when you ignore, dismiss, or suppress odd pieces of data, you use your thinking to build a sand castle of imagination, the basis of “conventional wisdom.” Illusion is great for authors, playrights, and movie makers, but not so great for scientists. For example, as I noted previously, a recent journal article by John Bailar, M.D, Ph.D., Chair of the Department of Public Health at the University of Colorado, pointed out there has been no significant decrease in the death rate from cancer in the last 20 years. Similar information has been published on mammography not providing any reduction in the breast cancer death rate, and so forth. Thus we are in illusion about the nature of the disease, the mechanisms of tumor growth, and the treatment of the problem.
Another important priniciple in the scientific method is that experiments must be able to be replicated by different individuals. So if you find yourself immediately discounting a set of data that is important, and that it upsets your applecart in some way, then if you practice the scientific method you owe it to yourself to replicate the experiment and prove it wrong or right. As many innovators have discovered, the most interesting and important data is the data that does not fit the current scientific paridigm because that is exactly where new breakthroughs occur.
So virtually all great scientific breakthroughs punch holes in conventional scientific thinking and show that the old way was, as least in some sense, an illusion. As Thomas Kuhn has pointed out in “The Structure of Scientific Revolutions,” scientists often hold on to old illusions until they die and a new generation has to come along to adopt new science which does a better job of explaining or incorporated new facts. Peter Drucker points out the same phenomenon in “Innovation and Entrepreneurship.” Any new innovation is at high risk of the “cuckoo” effect. The cuckoo lays it eggs in other birds nests. If the other bird realizes this, the eggs are destroyed. Any organization instinctively tries to eliminate anything new and unusual that appears in its midst, and scientists are not exempt from this psychological problem.
This is particularly true in medicine, which is still more of an art than science. Despite the lip service given to “evidence based medicine,” i.e. medicine based on replicated studies in the major journals, over 80% of medical practice is not evidence based. And many practices that have been proven to be useless in the journals are still practiced extensively. As the Institute of Medicine has noted, many practices which kill hundreds of thousands of people every year have been clearly documented in the literature as bad practices, yet people and insitutions ignore them. Tradition has been more important than medical safety.
We need innovation in medicine and it will not come from business as usual!