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Send to a FriendRalph Lewis has had a long and distinguished career in thoracic surgery. A surgical innovator and pioneer in his specialty, he was experimenting with mini-approaches to thoracic problems long before these approaches became popular. He introduced the use of video imaging with minimal techniques, chaired the comittee that coined the term 'video-assisted thoracic surgery (VATS),' and championed its use long before the technique became a daily part of the thoracic surgeon's armamentarium.
Thomas Ferguson, MD
Senior Editor
CTSNet
“It is the customary fate of new truths
to begin as heresies.”
- Thomas Huxley-
An idea is like a shooting star bursting forth with brilliant illumination but dimming and disappearing ever so quickly. At one time or another almost everyone gets a good idea, and some even get several good ideas. Either from a lack of motivation, or from a mysterious inability to proceed, or for various unknown reasons, few people make a serious attempt to develop an idea. Unfortunately, only a fraction of even this small enthusiastic group will ever bring their original idea to some kind of fruition. These few are characterized as innovators who persevere despite almost impossible obstacles confronting them.
An evolving idea is like a growing child. Only the parent seems to know what is best. Just as well intentioned criticism of a child, by others, is not readily appreciated, so in many instances, is criticism of an original idea. Advice by strangers to parents, on how to make their child behave better is seldom, if ever, heeded, so also with unsolicited advice about a new idea. Derisive criticism should be refuted , however, constructive recommendations should be evaluated, accepted with gratitude when relevant, and implemented where suitable.
In some instances, any type of criticism could be misinterpreted, by the innovator, and could engender a defensive , confrontational demeanor. These well meaning and potentially valuable suggestions may even be ignored. If the innovation truly has benefits then the real loser becomes the patient who must await resolution of a sometimes long and arduous debate. The pioneer must avoid ego skirmishes during this early, crucial phase. The important debate is not about the innovator but should focus completely on the idea.
Immediate and complete acceptance by everyone is rarely a reality and almost never occurs. Critiques advocating rejection, because of perceived deficiencies, are much more likely and should be anticipated. This should not impair, in any way, the initial, innate enthusiasm and motivation to pursue, refine and bring the project to fruition. After all, if it is believed this idea will benefit patients, then criticism should not be allowed to intimidate or act as a deterrent. Many superb ideas that brought magnificent benefits to mankind were disparaged initially, and some required long periods of time before universal acceptance could be attained. Sometimes, the greater the contribution the more intractable the criticism. Colleagues may not always extend a welcome supportive hand or even evaluate new discoveries in a comprehensive, neutral and scientific manner. Instead they more often approach these new ideas with relevant but provocative inquiries. At inception, it is possible that even loyal associates may not discern its true value and fail to support it. During this period of time, careful and discreet responses by the pioneer are required to maintain adequate social and work relationships. Discourse must remain on a firm scientific plane at all times. Some will prefer to remain with the status quo and favor conventional methods. These positions must be respectfully abided.
Many surgeons of the past, who were castigated by their peers for advancing seemingly ludicrous ideas, are acclaimed by the present medical generation for their invaluable contributions. History is replete with unfortunate dismissals of ideas that eventually proved to be extremely important and led to tremendous, beneficial medical advances. Numerous examples can be retrieved from our medical literature, but two of them, involving surgeons, are worth reviewing briefly.
Smallpox was one of the worst scourges to ever afflict mankind. Kings, Queens and tens of millions of common people perished receiving the accepted, state of the art, traditional therapy which was aggressively advocated and administered by the leading medical universities and their esteemed practitioners of that era. Edward Jenner, a young surgeon practicing in Gloucestershire, England, recognized that milkmaids whose hands became infected from pustules on the cow’s udder did not contract smallpox. In 1796, he scratched this offensive purulent material onto the skin of children. This minor procedure seemed to protect them from the morbidity and mortality of smallpox which was devastating all of Europe.
Jenner sent a medical paper describing this simple technique to the Royal Medical Society. It was brusquely dismissed and returned with disparaging comments. The treatment was considered too loathsome to even evaluate. He was cautioned about damaging his reputation if he persisted in this folly. Two years later, after treating numerous patients successfully, and, at his own expense, he published a pamphlet describing his method and results. This was greeted, once again, with criticism, skepticism and sarcasm by distinguished colleagues. Many years were to pass before acceptance was accorded this ingenious life-saving technique which became known as vaccination.
Arrogance, ignorance and closed minds by the leadership of the medical community resulted in needless deaths for millions of people for many years throughout Europe. Even up to 1958, ten to fifteen million people still contracted smallpox each year and two million died annually. It was not until 1986 that the World Health Assembly declared the world free of smallpox. This was almost 200 years after the introduction of the technique of vaccination. Edward Jenner, who saved countless millions of lives, was never knighted for his magnificent contribution.
Werner Theodor Otto Forssman, a surgeon, performed the first cardiac catheterization in 1929, on himself, by passing a ureteral catheter 65 cms. into the antecubital vein. He then walked a long distance to the x-ray department where the tip of the catheter was confirmed to be in the heart. Forssman continued these experiments, and after numerous tests began to inject contrast material into the catheter. The cardiovascular system could be visualized as never before seen. He immediately understood the value of this new technique for studying cardiac metabolism and abnormalities, however, colleagues, in leadership positions, neither appreciated nor realized the immense potential of this unique approach. Instead of accolades, he was severely and intensely criticized for performing such a repulsive procedure. He lost his appointment, and one professor even predicted that his ideas would cause him to end up in a penitentiary. He received no academic or financial support but only contempt and disrespect for his ludicrous procedure. In reality, his foresight, perseverance and innovative mind played a major role in pioneering the field of cardiac surgery. Twenty seven years after his original publication, which brought derision, financial ruin and loss of his academic position, Werner Forrsman received the Nobel Prize.
These are not isolated cases since surgical history is crowded with many similar episodes. An idea can encounter resistance when it does not conform to current accepted medical practices. Early pioneers in cardiac surgery, pacemaker implantation, transplantation etc. commonly experienced repudiations . Often, they became vulnerable targets at meetings. Fortunately, the persistence of these bold trailblazers opened new vistas for all cardio-thoracic surgeons which have resulted in a host of new life-saving benefits for a multitude of patients.
Bringing forth and trying to promulgate a new idea in medicine is inordinately difficult, and, in surgery, it can be almost impossible. By nature, most surgeons are conventional, conservative, highly organized, disciplined individuals who devote many years to learning and mastering specific, essential skills necessary for performing complex surgical operations. Abundant pride, unbridled confidence and a unique intuition all add to the self-assurance so important for the pursuit of the lofty endeavors of surgery. Once successful in their technical activities, surgeons can become unyielding to any suggested modifications or changes in their work habits. Any new idea or proposed revision of a traditional operation immediately invokes suspicion and skepticism. Actually, for surgeons these are truly meritorious traits since surgery is permanent and, in many cases, irreversible. A second chance is seldom permitted as in other fields where a medication can be changed or discontinued. A surgical procedure must be performed efficiently, correctly and skillfully the first time. Although surgeons should be commended for these esteemed attitudes, on occasion, these same laudable traits can result in delay, or even the neglect of new beneficial techniques. Anytime there is a transition from the reliable, successful, traditional method to the new innovative technique, a rush of apprehension can develop in the surgical community which must be recognized and appropriately addressed. Skills developed for traditional techniques may not always be applicable to the new procedure. In fact, new skills may have to be developed and, depending upon the difficulty of the learning curve, can result in frustrations, understandable resistance, and, ultimately, even denial of the new approach. The innovation may no longer be judged only on its true merits.
Surgeons properly, correctly and ethically seek vast amounts of information before accepting and performing a new procedure. Obviously, for any new operation, this compilation of knowledge will not be available for prolonged periods of time i.e. random trials, results from large series, long term follow-ups, etc. Since the innovator is also on a learning curve and does not possess full knowledge or a complete understanding of the new technique, satisfactory explanations or comprehensive answers to the many pertinent and important questions being asked are not always immediately achievable. Often fragmentary information extracted from a partial or superficial understanding of the new method is all that is available. Unfortunately, this can be utilized by critics to make comparisons to the traditional approach for which an abundant amount of information has been gathered, analyzed, scrutinized and reviewed for many years. Statisticians have challenged the validity of comparing evolving surgical techniques to established, traditional operations for which there is much more knowledge and experience. The innovator must address these unequal comparisons in a prudent, relevant and scientific manner.
Even after the new technique has been demonstrated to be safe, successful and beneficial in a small number of patients, many questions will still remain that can require years of careful scientific study for a satisfactory resolution. Interestingly, even today, stimulating debates still occur frequently at surgical meetings concerning the most appropriate application and value of mature, accepted, traditional surgical procedures that have been studied and utilized for years. One can hardly expect complete and conclusive answers to accompany the initial presentation of any new surgical technique.
Confirmation of validity and effectiveness becomes the task of those surgeons who aspire to a more efficient and beneficial treatment for their patients. A major contribution to patient care begins to evolve when this enterprising faction starts to perform the new procedure with all necessary care and concern and also begins to accumulate much needed and important information. If the technique is valid, many answers to questions will be forthcoming as experience and results are acquired and evaluated. A truly valid idea should be able to endure and even prevail despite intensive examinations. The great majority of surgeons will remain in the center listening, learning and deciding as the pros and cons are presented. This knowledgeable, fair, neutral and quiet majority, in good time, will make the final decision about the validity and benefits of any new surgical procedure.
It must be realized that bringing an idea to fruition is a monumental project consisting of immeasurable amounts of hard work for which there may be no immediate reward but instead a plethora of renunciations. Shepherding any new idea around the many and various obstacles, that sporadically erupt, can be a daunting and exasperating assignment. Pioneering anything is not for the faint hearted. It demands a large reservoir of motivation, determination, persistence and an absolute and sincere belief that it is a good, sensible idea that will benefit patients. Resilience, cordiality, some thick skin and, above all, perseverance are all essential for success.
Although the current system can be somewhat heavy-handed, nevertheless, since there is much at stake for the patient, it still remains an ideal and necessary process for separating the good ideas from the bad. The various maneuvers utilized, by others, to rigorously dissect, challenge and scrutinize any new idea should never be taken personally by the innovator. Anyone who has a good idea and truly believes in its merits should enter this exciting arena with enthusiasm, humility and an attitude receptive to both the skepticism and the constructive criticism that it will generate. Exposing your idea, for the world to scrutinize, undress, and judge, is an essential requirement needed to fully test its credibility. Everybody who disagrees with you is not necessarily against you or your idea but, in reality, may be exposing possible flaws in your hypothesis. Many will try to help, give support, and even commend your efforts. There will always be a small group of concerned critics who will counter with well-intentioned but formidable arguments. Gladly, accept and respect these queries and answer them to the best of your ability. Evaluating and addressing dissenting comments can be frustrating, but, in reality, can also be much more valuable and productive to the future success of any endeavor than passively accumulating accolades. You must constantly remember that the first steps are always the most difficult and that is when one commonly stumbles. At inception, any idea will have many rough edges, yet, these early, crude versions will gradually become refined, and improved with time, experience and, most importantly, from the invaluable suggestions and numerous contributions of others.
Finally, to all of you harboring a good idea but are reluctant to say anything about it – go for it. If everyone likes your idea, re-evaluate it. It may be too close to the conventional and traditional to be of any consequence. If your idea is called ludicrous, nurture it. This one, possibly, could make a significant impact on the field. Do not be discouraged even though early on you may not be given the reception you would have preferred. Approach it in a proper and appropriate manner—it will be a lot of fun. Poor ideas do not survive no matter how much support they receive, whereas, good ideas cannot be suppressed no matter how much opposition they encounter.
“The pioneers, the first who struggle out of the established systems and who form new and useful conceptions, appear only half right, incomplete; and their names stay remote. But they are perhaps more to be honored than those who come after, who clear off the debris and offer a neater, more full-blown view.”
- Jacques Barzus-