While simultaneously delighting in Matt Ridley’s book The Rational Optimist, coupled with Thomas Hager’s The Demon Under the Microscope and a string of books on innovation,* I’ve been struck repeatedly by an idea that I first encountered in Jared Diamond's Guns, Germs, and Steel—Invention is the mother of necessity.
As the scientist Terence Kealey has observed, modern politicians …. believe that the recipe for making new ideas is easy: pour public money into science, which is a public good, …. and watch new technologies emerge from the downstream end of the pipe. Trouble is, .... science is much more like the daughter than the mother of technology....
According to Ridley, the industrial revolution was driven by innovation in the textile industry, the science of which was so simple that it wouldn’t “have puzzled Archimedes.” Similarly, the men most responsible for advances in the steam engine were largely ignorant of scientific theories. Rather, it was the development of the steam engine and the subsequent incentive to refine it that drove the theories of thermodynamics, not the other way around. Scientists did not first flesh out the laws of thermodynamics, and then set about building steam engines.
Fast-forward to the early days of computers, where the element that touched lives, the personal computer, was truly launched in “the garages and cafes of Silicon Valley” rather than the research labs of the day.
To be sure, these research labs offered refinement and insight that dramatically deepened the impact of these developments. But again, putting scientific theory is more the cart to the computer industry's horse. Ridley comments:
In a lecture on serendipity in 2007, the Cambridge physicist Sir Richard Friend, citing the example of high-temperature superconductivity—which was stumbled upon in the 1980’s and explained afterwards—admitted that even today scientists’ job is really to come along and explain the empirical findings of technological tinkerers after they have discovered something.
The inescapable fact is that most technological change comes from attempts to improve existing technology. It happens on the shop floor…. among the users of computer programs… and only rarely as the result of the application and transfer of knowledge from the ivory towers of the intelligentsia.
Consider some highlights of discoveries made in total scientific ignorance: Ridley cites the use of aspirin, lime juice for scurvy prevention, and preserving food absent of explanatory theories. Thomas Hager describes the remarkable story of how sulfa and penicillin antibiotics were discovered far in advance of bacterial cell physiology. Their genesis in serendipity belies their significant contributions to standards of living.
Before proceeding, I have to make it clear that I'm in no way advocating abandoning medical research, nor am I criticizing those who dedicate themselves to its pursuit. I'm merely exploring ideas to optimize our good intentions.
So where does that leave us today?
Despite the soft-hued images of lab spaces filled with dispassionate scientists that patients see on TV; the pace of innovation in medical care is lamented every time a mother has to take off a half day of work to sit for hours in a waiting room with her sick child simply to get a prescription for an ear infection. Why is medical innovation so slow compared to the exploding advances in industries like information technology?
I propose that medical innovation is slow because creative mistakes are not allowed. Brief reflection will confirm a world of difference between releasing a glitchy mobile phone app and promoting a faulty medication.
Understandably, medicine operates on trust and reliability. Therefore, its innovation model centers on careful, deliberate laboratory science that translates, in Ridley’s words, “knowledge from the ivory towers of the intelligentsia” to actual patient care. The best and the brightest are encouraged to study in the most prestigious institutions, where the pool of knowledge is both vast and unprecedented. This knowledge is then distilled in the lab and applied to treatments in a calculated and safe manner, free of creative mistakes. The last thing a patient wants to hear is that their caretakers are tinkering with their management.
According to the accounts of Ridley and others, translational research is in such need precisely because it so rarely works. Applying advances in the lab to patients in the hospital is so difficult because, as John Ioannidis points out in his important paper Why Most Published Research Findings are False, it is hard to translate research findings that aren't true. Intriguingly, the more ensconsed the author is in the ivory tower, the more likely it is wrong. The strategy of applying science in a top-down fashion is severely limited compared to the unscientific tinkering that drives other industries.
For medicine to advance apace other industries, it must enable creative mistakes. Since patients must be shielded from these mistakes, both bodily and institutionally, engendering such tinkering requires careful monitoring and control. Therefore, I propose hospitals establish departments of innovation. Full time staff would support healthcare providers at all levels, from doctors and PA’s to nurses, IT staff, custodial staff, and administration, to share ideas and try them out. For some, tinkering would be their focus rather than an occasional side project.
Most intriguingly for me, such a department of innovation could harness the power of medical students. Medical students represent a parallel stream of clinical care. They interview and examine patients, check up on their labs and tests, and write up detailed assessments and plans, all secondary to the patients' actual care. Such a system is ideal for proposing "what if" questions and generating safe mechanisms to test them; ideal for creative mistakes. This offers a tantalizing means for medical education to drive advancements in the field rather than lag behind them.
Personally, I'm wondering if we're not fooling ourselves by encouraging our best and brightest to spend years of their lives, and huge swaths of public money, on the top-down science strategy? I have no doubt that the prestige of these institutions and this career path drives many to choose it. Tinkering doesn't have much prestige, and it never has. (See my post on tweaking the system.) Perhaps a department dedicated to innovation can encourage some of our talented students that tinkering isn't so low-brow?
1- Progress is driven more by mistake-laden tinkering than top down science.
2- Medical innovation is hampered because its current structure can't tolerate creative mistakes.
3- A department of innovation could enable creative mistakes while shielding patients from its effects.
4- Medical students provide a parallel system of patient interaction amenable to safe tinkering.
* Other books on innovation:
Where Good Ideas Come From by Steven Johnson
Making Ideas Happen by Scott Belsky
What Technology Wants by Kevin Kelly
I Live in the Future, and Here's How it Works by Nick Bilton