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I'm a radiologist and writing helps me make sense of the world.

"My method is to take the utmost trouble to find the right thing to say, and then to say it with the utmost levity" -George Bernard Shaw

Saturday 8 May 2010

Innovation and The Cup of Knowledge

The broadcaster John Humphrys talks of “hurrah” and “boo” words. This linguistic tactic tries to persuade us of something by the use of associated positive or negative words. If something is new, modern, scientific and progressive it can be easily championed. Conversely labelling something with a “boo” word such as old or traditional is a sure-fire way of killing it off. Surely “innovation” has become the ultimate “hurrah” word for the 21st century NHS.

Except it is now more than a word, bigger than an aspiration. Innovation is a now formal part of NHS infrastructure. There is now an NHS Institute of Improvement and Innovation; there are nine “NHS Innovation Hubs” in the UK and a £240m Innovation Fund has been introduced.

This unfettered embrace of innovation in the NHS is perhaps one of the defining motifs of the decade. If it isn’t innovative, you can go whistle. Common sense, clinical experience and empirical evidence are dismissed as bourgeois indulgences in a headlong rush for things modern and novel. Lysenko would be very proud! It is my nihilistic contention that innovation needs to be viewed with extreme scepticism.

Benefits of innovation

It is always hoped an innovation has fundamental advantages over a more traditional method. However, this is often unknown at the time of implementation. Paradoxically, once an innovation is empirically studied, it ceases to be innovative anymore. In truth, most innovations happen because there is always more excitement about new and different. There are subtle yet well-studied interactions at play here.

First (and best studied) is the Pygmalion effect. This refers to situations in which people perform better simply because they are expected to do so. It entails a complex unconscious interaction involving verbal and non-verbal cues. It is named after George Bernard Shaw’s play Pygmalion (later popularized by the musical My Fair Lady), in which Henry Higgins believes that the Cockney flower girl, Eliza Dolittle, can be made into a lady. Higgins’ belief in her is a strong factor in her decision to become one.

Second is the Hawthorne effect. This phenomenon refers to improvements in productivity or quality or work that results from the mere fact that workers were being studied or observed. It is named after a study at the Hawthorne Plant, near Chicago from 1924-36. It is widely invoked to describe an improvement in performance following a newly introduced change. There is no doubt that the presence of an influential figure alters the situation as workers may want to avoid, impress, direct, deny or influence them. Moreover, this is to an unknown and unpredictable degree. This consideration is well known in qualititative research and is known as “reactivity”.

Lastly, the Halo effect, where the individual performs differently because of the novelty of participating in something new. Performance can improve from an unjustified belief in its superiority. It shares similarities with the placebo effect.

After the innovation?

Virtually anything that is new will be popular at the time of its introduction and for a few years thereafter. It is axiomatic that at least 75% of innovations will have a half-life of less than five years. This isn’t surprising. Interest waxes and wanes as the enthusiasm and/or responsible personnel behind it vary.

One reading of this is an order effect. The most recently adopted approach attracts the most enthusiasm hence it will always win. This leads to a purgatory of constant change and enforced adoption of innovation. Such enforced redefinition, reinvention and reclassification indeed blights the modern NHS – “digging up the trees they’ve just planted” as it was memorably described recently [1]. This is flanked by a concurrent fixation with all things new. Sparkly ideas, twinkling notions and shiny concepts are gathered and vaunted by distinctly magpie-like NHS apparatchiks.

The converse can be true. What was new, radical and exciting will inevitably undergo heterotopic ossification, becoming fixed and immutable. Old isn’t always bad – it is madness to dismiss the old without evidence of inferiority. On the other hand, if you do so these days and call it an innovation, such evidence seems to be optional.

And this is my main point: change should be driven not by political fashion but by evidence that it is an improvement. Sadly, it is neither an original nor new point. Over 80 years ago, Sir Robert Hutchison most eloquently put it thus [2]:

“Those of us who have the duty of training the rising generation of doctors have a great responsibility. We must not inseminate the virgin minds of the young with the tares of our own fads. It is for this reason that it is easily possible for teaching to be too “up to date”. It is always well, before handing the cup of knowledge to the young, to wait until the froth has settled.”


1) BMJ 2008: 336; 919
2) BMJ 1925: 1; 995-8.

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