Milestones on the long road to knowledge

Seeking a way to mark the launch of the new BMJ, we hit on the idea of looking back at the most important medical milestones since the forerunner of the BMJ was first published in 1840. We asked readers to nominate milestones, which you did in good numbers. A panel of editors and advisers narrowed the field down from more than 70 to 15. We invited champions to write on each one; their contributions make up the commemorative supplement we are publishing on 20 January. And we are now inviting readers to vote for which you think is the most important of these medical milestones (see bmj.com). The result will be announced on 18 January.

Medicine is about stories—the patient's account, the doctor's interpretation, the detective work of diagnosis, the research journey—and these 15 accounts are all good stories. They combine all the elements of good fiction: serendipity in the discovery of penicillin (doi: 10.1136/bmj.39021.640255.94) and x rays (doi: 10.1136/bmj.39052.527396.94); sheer determination in the development of tissue culture (doi: 10.1136/bmj.39034.719942.94); raw personal ambition—the emergence of ether as an anaesthetic owed much to one dentist's desire to advance his position (doi: 10.1136/bmj.39034.661377.94); competition in the publication race over chlorpromazine (doi: 10.1136/bmj.39034.609074.94); drama in turning off the Broad Street pump (doi: 10.1136/bmj.39044.508646.94); and tragedy in the death of a friend, which led Semmelweis to his discovery (doi: 10.1136/bmj.39044.597292.94).

Some of the 15 may surprise you. Does it make sense to give milestone status to evidence based medicine? Perhaps it says something about the culture of medicine that an effort to systematise our relation with science should have proved so controversial. As Kay Dickersin and colleagues say (doi: 10.1136/bmj.39062.639444.94), how can something so intuitively obvious to lay people—the need to make decisions on the best available evidence—not be similarly viewed by clinicians? You'll also no doubt find omissions. Jeffrey Koplan finds several when he compared our list with one he initiated for the US Centers for Disease Control eight years ago (doi: 10.1136/bmj.39049.680683.94). I've found some too. Where are aspirin, Helicobacter pylori, and Medline?

But given that these 15—all extraordinary medical advances—are what we have, how should you decide? If your vote is based on the number of lives saved, vaccines (doi: 10.1136/bmj.39045.558889.94) seem hard to beat; if it's societal consequences, you might have to go for the pill (doi: 10.1136/bmj.39051.582546.94). (As Carl Djerassi points out, there's no need to ask which pill, so enough said, perhaps.) Alex Jadad and Murray Enkin sweep up the whole history of human intelligence in their enthusiasm for the role of computers in medical advance (doi: 10.1136/bmj.39038.663970.94). How can humble oral rehydration therapy (doi: 10.1136/bmj.39044.725949.94), the simple addition of salt and sugar to clean water, compete with that? At least on the grounds of cost effectiveness it can.

What can these 15 milestones tell us of medicine's future prospects? Will genetics deliver on its promise of real clinical benefit? John Burn says that the best is yet to come (doi: 10.1136/bmj.39051.647963.94). The same might be said of monoclonal antibody technology: will it deliver vaccines and safer treatments for chronic illness (doi: 10.1136/bmj.39044.641817.94)? Our understanding of the risks of smoking may be, as Simon Chapman confidently asserts, “all done and dusted” (doi: 10.1136/bmj.39035.657095.94), but can we share his confidence that the end game for smoking may be just 20 years away? And will we have the wisdom that Jadad and Enkin believe is necessary to ensure that computers help us to transcend all our boundaries rather than contributing to our extinction?

Finally, what do these stories tell us about how medicine advances? The image of researcher as hero is compelling and central to many of these stories. But as Geoff Watts says (doi: 10.1136/bmj.39034.682778.94), a fixation with breakthroughs skews the picture of how science really progresses: “Knowledge doesn't suddenly appear in neat and tidy quanta. Like patches of lichen spreading over a rock face, it accretes over decades.” It follows that we can't rely on the chance arrival of genius in our midst to take us forward to the next era of discovery. Knowledge and its implementation need an infrastructure that supports applied as well as basic research, encourages the systematic implementation of what we already know, nurtures young talent by creating career structures in research, and encourages commercial investment while protecting against the erosive influence of vested interest.

Knowledge and its implementation also need effective channels for communication. The BMJ has played a direct part in at least one of these advances and has born witness to all of them. Now the new BMJ provides an even better (and better looking) communication channel—a space in print and online where researchers and clinicians can meet, where they can share what they have experienced, thought, or found and where others can confirm, refute, build on, reject, or implement their findings. The new BMJ will save you time and effort by covering the important developments in medicine. It will present the evidence based certainties where they exist and the controversies and debate where these are needed. Our aim is to create a journal that helps doctors make better decisions—whether in clinical practice, public health, policy making, or research—to improve the future care of patients. Now it's down to you to decide which of these 15 milestones deserves your vote.