An article titled “Opportunity Knocked, They Didn’t Answer” that appeared in The Wall Street Journal on October 22, 2021, pointed out that in many cases when a solution or remedy is presented, its benefits are not recognized at the time and many years pass before the solution is accepted by the healthcare profession.
The article offered two examples that have relevance to healthcare. The first example in the article involves playwright George Bernard Shaw, who was approached by two Viennese composers who wanted to create an opera based on his Arms and the Man. Although Shaw perceived their idea to be an “abasement” of his masterpiece, he granted the adaptation rights to the composers, but, as a matter of principle, refused to accept any royalty payments. The operetta was wildly successful in London and sold out to audiences in New York. It made its creators a fortune in royalties, but Shaw never saw a penny from the show.
The second example story involves a Houston chemist, Norman Stingley, who invented a polybutadiene rubber substance that was very bouncy. At the time, 60 years ago, Stingley offered his invention to the owners of the company where he worked, but the offer was rejected because of the substance’s lack of durability. Stingley then took his creation to the Wham-O toy company (makers of Hula Hoop and Frisbee), and the Superball was born. Over 20 million of these bouncy balls have been sold, making both Wham-O and Stingley financially successful.
What’s the take-home message? Be careful when you say “no.” You may have just rejected the best play on Broadway or the next bouncy ball.
How does this apply to healthcare?
Medical students are focused on listening to lectures, reading, memorization, and the ability to recall information for testing purposes. Acronyms and mnemonics are used as prompts to remember the 12 cranial nerves, or the acronym RICE (Rest, Ice, Compress, Elevation) for the treatment of soft tissue injuries, or to recall the eight carpal bones of the wrist (Some Lovers Try Positions That They Can’t Handle). As a result of this educational philosophy of rote learning and memorization, there is little room for creativity in a medical student’s early career.
What are some examples of creative thinking in healthcare? In 1895, Wilhelm Roentgen observed an image of his wife’s hand and ring on a photographic plate. Just one year later, in 1896, x-rays were being used clinically in the United States for evaluating bone fractures and gunshot wounds.
Perhaps the most difficult part of a new discovery is convincing others of the benefits and improvements in care provided by the new discovery.
In 1928, when Alexander Fleming returned from a vacation, he observed that one Petri dish in his laboratory had become contaminated with a fungus, and that the colonies of staphylococci immediately surrounding the fungus had been destroyed. This observation ultimately led to the discovery of penicillin, which changed the course of medicine in the 20th century.(1)
An example of identifying a problem and then finding a solution comes from one of our practices (NB). Nearly every day, one or two patients called with urgencies or emergencies that required same-day appointments. Rather than tell them to just come in, thereby creating a delay for patients who had scheduled appointments, a 15-minute opening was created at the end of each morning and the middle of every afternoon to make room to see those patients who needed same-day appointments. This solution allowed scheduled patients to be seen on time and yet accommodate patients who needed to be seen that day.
Use of the Mercury Thermometer to Evaluate Body Temperature
Since the earliest days of medicine, physicians have recognized that the human body can exhibit an abnormal rise in temperature, usually defined as fever, as an obvious symptom of certain illnesses. For example, there are early references to fever in the book of Job in the Bible, and there are descriptions of “burning bones” in the book of Psalms. Physicians were very accustomed to using their hands as a means for estimating a patient’s temperature.
In 1714, Dutch scientist and inventor Daniel Fahrenheit invented the first reliable thermometer, using mercury instead of alcohol and water mixtures. By observing the correlation between a patient’s change in temperature and the physical symptoms of the illness, he concluded that a record of one’s temperature could inform the doctor of the patient’s health. However, the early mercury thermometers were not met with enthusiasm by his peers, and the medical thermometer was rarely used due to fears of the danger of placing a glass tube filled with poisonous mercury in a patient’s mouth.(2) It was not until nearly 150 years later that Carl Wunderlich published temperature recordings from 25,000 patients—amounting to more than 1 million readings—and established a normal range of temperature from 36.3°C to 37.5°C. However, in the mid-19th century the medical thermometer was still a foot long and required 20 minutes to take an accurate reading. As a result, its adoption as a replacement for the physician’s hand on the forehead to determine a patient’s temperature was slow in coming.(3)
Ignaz Semmelweis and Handwashing
Hippocrates identified puerperal fever nearly 2500 years ago and noted that postpartum women with a foul-smelling vaginal discharge and fever died shortly afterward. In the mid-1800s, doctors believed the culprit was miasma or “bad air.” In Vienna, Dr. Ignaz Semmelweis was puzzled by the discrepancy between the increased mortality when babies were delivered in the doctor’s clinic compared with those delivered by midwives in the midwife clinic. Semmelweis was a careful observer and eliminated possible causes between the two clinics. He was baffled, because he thought that doctors, because of all their years of training, should be better at delivering babies than midwives. Doctors chalked up their increased mortality rate to the lower socioeconomic status of the women whose babies were delivered in the doctor’s clinic groups. Semmelweis even looked at the days of the week when most of the deaths took place and could not find an explanation.
Semmelweis noted that physicians often placed their hands on their aprons, and that those aprons contained residues from previous autopsies. He observed this transmission from the cadavers of the women who died of puerperal fever to the doctor performing an autopsy, and then to a pregnant woman about to deliver a baby. He believed he had discovered “cadaverous particles in the doctor’s clinic” that were responsible for childbirth fever and maternal death. Semmelweis encouraged other doctors to wash their hands with chlorinated lime (bleach) after doing an autopsy and before going to the delivery ward. After just one month of this handwashing regimen, the mortality rate plummeted from 20% to 2%.(4)
Even when Semmelweis shared his results of handwashing decreasing puerperal fever, however, other doctors did not take responsibility for the spread of disease and refused to believe that handwashing was responsible for the decrease in the death rate from puerperal fever.
Semmelweis learned that it was very difficult to change a person’s mind and that the status quo is hard to change in the healthcare profession. This phenomenon often is referred to as belief perseverance, in which new ideas and approaches are rejected even when there is overwhelming empirical data that supports them.(5) This is perhaps one of the chief obstacles to the advancement of medicine. When a discovery is made, that is only half the battle. Perhaps the most difficult part of a new discovery is convincing others of the benefits and improvements in care provided by the new discovery. Today, Semmelweis is considered a genius, his work is celebrated in the medical field, and he is thought of as the “savior of mothers.”
Using Shock Waves to Manage Kidney Stones
Shock waves, first identified 130 years ago by August Toepler,(6) initially were known for their destructive effects, such as those seen with explosions, gunshots, and supersonic flights of airplanes. During World War II, it was noted that severe damage occurred to humans who were inside tanks that were struck with bullets or bombs. The impact of strong shock waves also was demonstrated in the 1995 terrorist bombing of the Murrah Federal Building in Oklahoma City. When a truck bomb was detonated a few meters from the building, the resulting strong shock waves destroyed the columns supporting the building, causing the building to collapse.
In 1974, a German urologist, Christian Chaussy, formed an interdisciplinary workgroup to conduct experimental and theoretical studies for the use of shock waves. The challenge was to see the destructive effect of shock waves as an opportunity, and to apply that effect to medical conditions, obtaining a beneficial effect without destroying normal tissue.
Going from laboratory experiments to a clinical prototype required a great deal of confidence, as well as efficient coordination between physicists, engineers, and medical doctors.
The clinical application of this novel technique, published at the end of 1980, was met with skepticism by the urological community.(7) The abstract that Chaussy and colleagues submitted to the 1981 meeting of the American Urological Association was not accepted because of “implausibility.” Nevertheless, extracorporeal shock wave lithotripsy (ESWL) has now been used to treat kidney stones in more than 50 million patients worldwide with great success, has reduced the morbidity from open surgery, and has reduced the cost of care for patients with nephrolithiasis.(8) Today, shock waves have been harnessed not only for kidney stone treatment but also for plantar fasciitis, erectile dysfunction, Peyronie’s disease, and other medical applications.(9)
Healthcare professionals throughout the world truly stepped up to the plate to address COVID-19, and doctors and researchers have been working furiously to address this pandemic and prevent future outbreaks. Doctors and other healthcare providers risk their lives every day to care for patients infected with COVID-19. What can we do to motivate our patients to practice good hand hygiene, wear masks, and stay at a safe distance from others?
Perhaps as we routinely ask questions about smoking, incontinence, and risk of falls and fractures, we could include asking patients about handwashing, masks, and safe distancing. We could wash hands in front of the patients demonstrating proper handwashing techniques. We could give our patients a reminder form or refrigerator magnets promoting regular handwashing. Also, we can show a YouTube video on the proper handwashing technique produced by the CDC to our patients in the reception area or in our exam rooms.(10)
Bottom Line: Healthcare is surrounded by opportunities for innovation and progress. We seldom recognize these opportunities, however, and we fall back to accepting the status quo. As the saying goes, “When opportunity knocks you have to answer the door.” This certainly is applicable to modern healthcare. No matter who you are and how long you have been in practice, we are certain that opportunity has knocked on your door, and you may not have answered. What bold accomplishments could healthcare achieve if we made the same level of commitment that President Kennedy made in the early 1960s (i.e., to put a man on the moon and return him safely to earth before the end of the decade)? What if world medicine made a global commitment to find a cure for cancer or the next pandemic before it affects millions of people? What if medicine initiated a global drive to eliminate obesity? What if we really determined which disease management programs are truly cost-effective to control the spiraling healthcare costs that erode the GDP of so many countries?
We need to take the opportunities that often appear and make healthcare better, safer, and more cost-effective.
We all need to think boldly and challenge the limitations that today’s medical community has imposed on us. We need to take the opportunities that often appear and make healthcare better, safer, and more cost-effective. The status quo may present obstacles, but there are some physicians who don’t see obstacles. They visualize opportunities—opportunities to improve the science of medicine, the quality of life of our patients, and the healthcare of our community, our nation, and our world.
Acknowledgment: The authors thank Dr. Christian Chaussy, Chairman Emeritus, Department of Urology, Klinikum Harlaching, Munich, Germany, for his contribution on the use of shock waves for the management of nephrolithiasis.
References
Macfarlane G. Alexander Fleming, the Man and the Myth. Harvard University Press; 1984.
Pearce JMS. A brief history of the clinical thermometer. QJM. 2002;95:251–252 .
Santorio S. In: Commentaria in Primam Fen Primam Libri Canonis Avicenna. 1625. Cited and illustrated by Lyons AS, Petrucelli RJ. Medicine: An Illustrated History. New York, Abrams, 1987:437
Adriaanse AH, Pel M, Bleker OP. Semmelweis: the combat against puerperal fever. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2000;90(2):153-158.
Maegherman E, Ask K, Horselenberg R, van Koppen PJ. Law and order effects: on cognitive dissonance and belief perseverance. Psychiatry, Psychology and Law. 2020;29(1):1-20.
Krehl P, Engemann S. August Toepler—The first who visualized shock waves. Shock Waves. 1995;5:1–18.
Chaussy CH, Brendel W, Schmiedt E. Extracorporeally induced destruction of kidney stones by shock waves. The Lancet. 1980;316(8207):1265-1268.
Woodhouse C. Landmarks in the management of urolithiasis. Trends in Urology & Men’s Health. 2021;12(3):29-32.
Loske AM. Medical and Biomedical Applications of Shock Waves. Springer, 2017.
Hand-washing Steps Using the WHO Technique. www.youtube.com/watch?v=IisgnbMfKvI . Accessed April 10, 2023.