Let's pension off the “major breakthrough”BMJ 2007; 334 doi: https://doi.org/10.1136/bmj.39034.682778.94 (Published 04 January 2007) Cite this as: BMJ 2007;334:s4
Look, I know we all love lists, competitions, prizes, and so on and that choosing the top 15 milestones in medicine is just a bit of fun. But, like the artistic and literary types who get sniffy about the Turner prize for art and the Orange prize for fiction, I'm going to be po-faced and argue that in one respect this enterprise is not only daft but damaging.
It plays to the “breakthrough” view of science: a wholly misguided notion that seeks to portray science as a kind of intellectual trawler. Under the guidance of its steersmen—the elite scientists high up on the bridge—the vessel charts a steady and calculated course across our sea of ignorance. Triumphant figures call down periodically to report that they have fished out another drifting barrel of knowledge and have drunk of the wisdom discovered therein. When what's found in the barrel is deemed exceptionally valuable—a “major breakthrough”—the crew members win medals.
In reality there is not one vessel but many; not one course but a thousand. And the information in the barrels often bears less resemblance to an illuminating draught of fine wine than to a small and bewildering cloud of fog. Which should be no surprise because, in truth, knowledge doesn't suddenly appear in neat and tidy quanta. Like patches of lichen spreading across a rock face, it accretes over decades.
Even medical research's brightest aren't always fully aware of the significance or meaning of what they're engaged in. A sometime colleague at the BBC World Service, a reporter, used to say that César Milstein didn't twig the likely practical impact of monoclonal antibodies until questioned about it by that reporter. As both men are now dead the claim is difficult to verify. But we do know for a fact what the Nobel prize winning immunologist Frank Macfarlane Burnet wrote 35 years ago about research in cell and molecular biology: “I do not expect conventional benefits to medicine or technology from biological research to be common in the future. If they should arise they can be accepted as bonuses, but need not be expected.”1 Isn't this a bit wide of the mark?
One man who did understand the fitful and faltering progress of science was Arthur Koestler. By charting the history of astronomy, with all its errors, misapprehensions, blind alleys, and perpetual shuffling between faith and reason, he exposed its true nature. He titled his magisterial account of our changing view of the universe The Sleepwalkers.2 The evidence is clear: there never has been a road map.
One of the most striking illustrations of the piecemeal accumulation of knowledge in science is the byproduct of a painstaking but largely forgotten study by Julius Comroe and Robert Dripps of the Universities of California and Pennsylvania.3 Using as an example the medical conditions most familiar to them—cardiovascular and pulmonary disease—they set out to show how clinical advances are often built on work that, at the time it was done, had no clinical application in mind. Their intention was to make a case for more spending on basic research. To demonstrate the value of research they systematically traced the sources of the knowledge underpinning 10 key advances made over the previous 30 years: the drug treatment of hypertension, for example, and the development of cardiac surgery. Comroe and Dripps then showed that these 10 advances were, between them, founded on what they described as 137 “bodies of knowledge.” Over several years they tracked down 2500 scientific reports that had played a major part in the development of these bodies of knowledge.
One of the 137 is the development of electrocardiography. As Comroe and Dripps say, “Some might consider that [Willem] Einthoven in 1903 invented the ECG [electrocardiograph] in its 1976 form without help from those who preceded or followed him.” Their survey paints a different picture. They discovered that well over 40 published reports had played an essential part in permitting the creation and refinement of electrocardiography. The first of these reports dated from 1660; the last appeared in 1967.
Their comment is as germane now as it was 30 years ago: “We believe that a major defect in education in science in high school and colleges is the perpetuation of the one person=one discovery myth … Marconi=wireless; Edison=electric light.”
While we're waiting for action on that front, how about a simple experiment? Try entering the phrase “major breakthrough” into the Google search engine along with the word “medicine.” On the day I tried it I got 309 000 hits. With so many major breakthroughs it's really rather difficult to understand why there are any medical problems left to solve.
So here's a modest but constructive proposal for starting to bring a little more realism to the discussion of new developments in medicine and medical research. Whether we're doctors or scientists, editors or reporters, let's all take a vow: to be parsimonious in our use of the term “medical milestone”—and to abandon entirely the words “major breakthrough.” Let this clichéd old soldier be pensioned off for good.
Right, got that off my chest. Now, back to that top 15.
Publication of this online supplement is made possible by an educational grant from AstraZeneca
Competing interests: None declared.