What can we learn from the great medical innovators of the past, asks David Jenkins
The covid-19 pandemic has the potential to transform medical education. [1] The ramifications of the pandemic have highlighted the requirement for innovation and the need to produce medical innovators as part of this transformation. There has been a longstanding emphasis on the need for basic science in pre-medical training. Over the past few decades, the number of students enrolled in medical school has grown to meet the needs of growing populations, so we are now in the position of producing very large numbers (20,000 annually in the US alone) of uniformly well trained physicians. These physicians are trained to apply evidence based medicine in a standardized fashion and have the best treatments at their disposal. But have we done enough to promote innovation?
To gain insights into what might be required to promote innovation in medical education, my colleagues and I assessed the early life histories of 100 great medical innovators since the Age of the Enlightenment (~1700). [2] Our aim was to determine their early life aptitudes and assess how they would fare as potential contemporary medical school entrants. We found that approximately 24% would unquestionably have been accepted by any medical school, 52% may or may not have been accepted, and 24% would likely have been rejected. [2]
However, I believe that we cannot afford to lose great innovators in medicine. The criticism that is often raised when we talk about the loss of innovators in medicine is that the problems we face today, for example with SARS-CoV-2, are more complex than those faced by innovators in the past where solutions, when obtained, were relatively simple. People argue that if we wish for innovation today, we should recruit those best trained in the basic sciences because this training will provide students with the basic knowledge needed to think about medical problems. But is this conclusion entirely true? Isn’t it also the way in which we think about a problem that is important, rather than just the complexity of the problem. And could we afford to look more widely at the skills that our medical students have beyond purely basic science. Do we need to select students for their critical thinking, and wider skills and interests, as well as their academic abilities? A look at some of the achievements of great medical innovators from the past shows that innovation and discoveries can come from a wide range of skills.
Edward Jenner (1797), with no knowledge of virology or immunology, used cowpox inoculation (vaccination) to prevent smallpox, a major scourge in the past that is now eliminated. [2] It is an unique achievement that may appear simple in retrospect when we reduce it to the simple facts. Would Jenner, who recognized the relation between cowpox and smallpox, also see a parallel between the common cold and SARS-CoV-2? It is along these lines that a group at Oxford have currently been testing a relatively innocuous chimpanzee adenovirus vectored vaccine for inoculation against SARS-CoV-2. [3] Is this innovation an extension of Jenner’s way of thinking?
Ignaz Semmelweis (1847) instituted handwashing to prevent puerperal sepsis based on his own observations [2]. Handwashing is now well established worldwide as a simple public health intervention to stop the spread of disease, no more so than in the current covid-19 pandemic. The benefit of this intervention is great, despite Semmelweis’ lack of relevant basic science knowledge.
In the Crimea war, Florence Nightingale created the concept of modern nursing as we know it . Her work contributed enormously to modern medicine today, for example to intensive care units, nursing, and modern statistics.
John Snow (1854) removed the handle from the Broad Street pump in Soho, London to prevent the cholera epidemic and ushered in the era of public health, a discipline of obvious relevance to our current pandemic.
How did they all achieve their successes so relevant to the current pandemic without a grounding in the basics of medical science? It may have been because of their ability to observe and think creatively.
What are some of the features of past great innovators, and how should the education system change to help foster the same creativity and innovation among current medical students? Perhaps the unifying feature is persistence (including after failure). Close second and linked to their persistence is nonconformism. They have come from diverse backgrounds, they may be brilliant all-rounders or show brilliance in only one area. They may be late developers. They may even have been failures initially. [2] Many would have lacked preparedness to enter the present medical system.
What these examples show us is that innovation and creative thinking can contribute towards medical discoveries and advances. We should not all be forced through the same hoop. Medical schools should look more widely when selecting future doctors. Transition courses can teach students the basics that are necessary for the study of medicine. The medical school must cater for the explorers, the curious, and the non-conformist. They must look for and encourage entrants from a wide range of backgrounds. Research electives and research funding should be part of undergraduate and post graduate medical education. It was a paid summer studentship that brought Charles Best to work with a young country surgeon, Frederick Banting, and laid the groundwork for the discovery of insulin.
The covid-19 pandemic invites change, especially change in what is considered basic for medical school entry and for the development of future medical innovators.
David J. A. Jenkins Professor of Nutritional Sciences and of Medicines in the Temerty Faculty of Medicine, University of Toronto and St. Michael’s Hospital.
Competing interests:
D.J.A.J., teaches and has selected potential medical students at the University of Toronto. He was not good at the basic sciences, specifically physics. He is grateful to Dennis Parsons, as the medical tutor at Merton College, Oxford, for accepting him to read Medicine, on the understanding that he would teach him concepts, recognizing his deficiency in mathematics. He has therefore always questioned what is basic.
References:
- Lucey CR, Johnston SC. The Transformational Effects of COVID-19 on Medical Education. JAMA 2020 doi: 10.1001/jama.2020.14136[published Online First: Epub Date]|.
- Jenkins DJA, Jayalath VH, Choo VL, et al. Does conventional early life academic excellence predict later life scientific Discovery? An assessment of the lives of Great Medical Innovators. Qjm 2020 doi: 10.1093/qjmed/hcaa210[published Online First: Epub Date]|.
- Folegatti PM, Bittaye M, Flaxman A, et al. Safety and immunogenicity of a candidate Middle East respiratory syndrome coronavirus viral-vectored vaccine: a dose-escalation, open-label, non- randomised, uncontrolled, phase 1 trial. Lancet Infect Dis 2020;20(7):816-26 doi: 10.1016/s1473-3099(20)30160-2[published Online First: Epub Date]|.
- Bliss M. Banting: A Biography: University of Toronto Press, Toronto, Ontario, Canada, 1992