Monday, January 17, 2011

A Department of Innovation: Allowing Creative Mistakes in Medicine

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.

Ridley states:
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?

In Summary:

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


mdstudent31 said...

Great post! Very thought-provoking!

"Scientists did not first flesh out the laws of thermodynamics, and then set about building steam engines." Really like this analogy!

"I propose that medical innovation is slow because creative mistakes are not allowed." - not only not allowed, but often ridiculed.

Also remember that most of this carefully, ethically-selected, patient-selected research occurs in huge academic centers where <5-10% of all patient care actually takes place. Most of the research out there is not actually research that is of benefit to the usual patient that walks into the waiting room at your typical community primary care practice. It is in the community, where >80% of care actually occurs, that we are indeed doing our own research. Most of it occurs with our patient interaction - did it work, did it not work, did you give it time, what were the side effects, how many other medications were you taking, etc etc. Perhaps this is where "creative mistakes" actually occur - in everyday practice that our published research fails to reproduce. And perhaps maybe we should focus more efforts and publications on research in the community rather than in the tertiary centers where, unless we are working there, we will rarely if ever see in everyday practice.

Hamsa Stainton said...

Good thoughts my friend. Question: How would a department of innovation do its tinkering while shielding them from its effects? Forgive my ignorance, but it's that what all the experiments on monkeys and so on all about? And would a dept. of innovation be significantly different that R & D departments?

astupple said...

Innovation is more like tinkering or tweaking. An example could be tweeting during a routine surgery so that patients, students and others could follow what it's like in the operating room. This runs the risk of hampering the procedure as well as divulging patient information, so a dept of people dedicated to this kind of thing could make sure it doesn't go wrong.

We're not talking big, risky experiments, just simple tweaks that may be helpful.

Miriam said...

Love it! The space to make mistakes is what is missing in government as well, in my opinion. The need to be careful and exact - however important - has an impact on the pace of innovation and the willingness of practitioners to create, test and play.

Related to this, however, is cost. For real and perceived reasons, the cost associated with innovating... and inevitably failing... is too great. This seems particularly true in life sciences/HC and is one of the key reasons, I think, that IT has taken off (low cost, high return).

I could imagine a Dept of Innovation being given a mandate to cultivate a few small-scale pilot projects that bring innovative practices into a hospital.

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