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Human knowledge, we are told, is growing exponentially, and so too, by
implication, is the development of technology. The theme of this
special issue of the Medical Journal of Australia is the
Impact of New Technologies in Medicine, and the Journal joins 43 other
medical journals internationally in exploring this theme.
Together, they create a global snapshot of the rise of technological
medicine at the close of the 20th century.
However, it is not just our ability to innovate that is growing. The
complexities of predicting the impact of new technologies on our
bodies, our society and our world are increasing too. For example,
while our ability to map the human genome and manipulate its structure
is only in its infancy, the speed of this technological development
has already outstripped our collective capacity to develop
appropriate moral approaches and social and environmental policies
about its application. The same group of technologies that might
deliver a cure for cystic fibrosis could also tamper with our food
crops, with possible widespread and unexpected
implications for public health.
So, is it time for the Luddite clan to regather, or is it time to take
another leap of faith into the future? This is the dilemma we have
already faced many times this century. The nuclear industry
developed both weapons of mass destruction and engines of energy, and
the debate raged about whether one was possible without the other.
With hindsight we now know that the two could not be
separated.1
An almost unspoken assumption about technology is that its
development is inevitable, and that, for good or bad, we must come to
terms with the changes that follow. However, technology does not
develop in a vacuum; the direction of its evolution is not a
fundamental law of nature. The potential for innovation is probably
infinite, and we make active choices in developing one set of
technologies over others. Since human resource is finite, we have to
ration our efforts. We see this in the often-implicit
priority-setting of governments, research-funding agencies and
industry.
As a community, we also make decisions to resist particular
innovations. Rogers' classic work The Diffusion of
innovations is filled with examples of the barriers that any
innovation must cross before it comes into common use.2 Among the
greatest of these barriers is the culture of organisations and
societies, because it is within cultures that we decide what is
valuable and what is not. Thus, in medicine, if a new technology is seen
to threaten our role as doctors or to diminish our importance, then it
is likely to be resisted. If our peers scorn the use of a
particular technology, or favour another, then we are more likely to
follow suit. So, our culture shapes the technologies we build and the
technologies that we adopt.
One of the problems facing practising clinicians is that much of the
technological innovation is coming from outside our own
professional culture. It is hard not to feel deluged by the offerings
of the pharmaceutical, biotechnology and information industries.
Why is the situation not reversed? What is it about the clinical
culture that makes us predominantly adopters of, rather than
innovators of, technology?
If we scan the pages of our medical journals, we see that much of clincal
science revolves around assessing the "evidence". Somehow,
whether consciously or unconsciously, clinicians have assumed the
role of gatekeeper, vetting the creations of others. But before a drug
or technology comes to randomised clinical trial, there has
been a long and expensive path of invention and experimentation.
Indeed, this hidden process of innovation applies to most
technologies, where probably only one in ten ideas makes it off the
drawing board and into an applicability trial.
When others are better equipped than clinicians to do the inventing,
the system works well. When clinicians are faced with challenges that
require us to be the inventors, we run into trouble. We are very good at
being critical and analytical, but are not used to being lateral,
fuzzy and playful in our thinking. New ideas require nurturing,
cajoling and bending and can easily get crushed if we prematurely
apply our skills of critical evaluation. Yet it is this creative and
necessarily fluid process of innovation that is desperately needed
today. Struggling with an ever more burdened healthcare system, we
know we must re-invent the way we work, and redefine our roles and the
way that we structure the delivery of care. To do this, we will need to be
as innovative as we are critical.
Unfortunately, the healthcare culture shares many of the attributes
of large organisations that struggle with, or fail to adapt to,
change. In common with many other established organisations, the
success of the existing way of doing business makes the cultural norm
one of steady, incremental change rather than radical change.
Further, the older the organisation, the richer are the
interdependencies between groups in that organisation.3 If one or more
small groups are threatened by an innovation, its passage through the
larger organisation is likely to be stifled. Indeed, those who study
the interactions between professional subcultures within
healthcare consider the conflicting beliefs of these different
groups to be a major barrier to health reform.4
If we look to the strategies of enduring organisations that
successfully adopt innovations, we see a willingness to recognise
that change is essential, and an ability to relinquish old hard-won
skills and ideas in favour of the new. Such organisations have the
skills to create a vision of what they wish to become, and to set about
making that vision come true. The process of continuous renewal is one
of seeking advantage in change, and of finding new evolutionary
niches in the changing competitive landscape.
So, if healthcare is to evolve in pace with the rest of society, it needs
to focus on creating a sustainable and flexible culture that does not
fear innovation. Whether we are enraptured by the promise of
technology, or are in fear of it, simply being reactive to its
development is not appropriate. Our culture's beliefs and values
shape what we create and what we dream. An anti-technology stand
leaves us room only to react to what is done by others, and, with the
potential to innovate accelerating as it is, now is the time to be
pro-active.
Many of us believe that medicine will be profoundly transformed in
this coming generation, and that our power to build new technologies
will be pivotal in engineering that transformation. But it is not the
technology that will transform medicine -- it is our vision of
medicine that will define the change. Our skills of invention will
then shape the technology we need to make the vision reality.
Enrico Coiera
MJA Guest Editor
Professor, Faculty of Medicine
University of NSW
Sydney, NSW
ewcATpobox.com
- Malchijiani A, Hu H, Yih K. Nuclear wastelands: a global guide to
nuclear weapons production and its health and environmental
effects. Boston: MIT Press, 1995.
-
Rogers EM. Diffusion of innovations. New York: Free Press, 1995.
-
Utterback JM. Mastering the dynamics of innovation.
Boston: Harvard Business School Press, 1994.
-
Degeling P, Kennedy J, Hill M, Carnegie M, Holt J.
Professional sub-cultures and hospital reform. Sydney: UNSW Centre
for Hospital Management and Information Systems Research, 1998.
©MJA 1999
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© 1999 Medical Journal of Australia.
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