Conclusion

The case studies contained in this volume offer a broad assortment of perspectives on medical innovation and bring to the fore a number of common characteristics of the process under analysis. First, the development of a new medical practice usually does not occur over short time spans but, rather, in most cases over relatively long periods. Both the material contained here as well as other case studies on the subject matter show that this is because the know-how that is relevant to the effect of restoring human health requires the vision, experience and expertise of different professionals, and of the institutions in which they operate. Accordingly, the learning process that drives the accumulation and cyclical adaptation of relevant know-how entails considerable efforts in the orchestration of different capabilities, perceptions and interests. A second prominent feature that stands out from reading the chapters is that the process leading to successful medical innovation involves significant uncertainty. This may regard not only the way in which a clinical problem ought to be addressed but also the very identification of what the problem is, and whether the particular remedies that are being developed are viable, effective and sustainable. As a matter of fact, tackling health issues entails working around the boundaries of that penumbra of uncertainty. It is therefore not surprising that the assessment of the reliability of a new clinical procedure is often compared with the trial and error learning that is typical of disciplines like engineering where experience is a key ingredient in the definition of workable solutions. Third, at times the achievement of effective responses to a medical problem occurs in the absence of a complete fundamental understanding of the disease. The contrary argument, that stronger scientific understanding invariably guides progress in medicine along a paradigm – borrowing from Kuhn’s terminology – leads to a mischaracterisation. Quite often improvements in practice stem from ways of understanding and from research routines that are developed with rather narrow goals in mind. If anything, the development of new diagnostic and therapeutic modalities are better understood as being own-standing paradigms, at times unfolding along competing directions. This is not to say that searches are random: they are ‘guided’ searches although their outcome is very rarely predictable ex ante. Also, this is not to lessen the importance of the path-breaking discoveries that originate from outside the realm of medicine and that have enabled better practice on several occasions. The last crucial feature of medical innovation that emerges from these chapters is that, while the conception and design of more effective treatments occurs at some distance from actual practice, there is a considerable amount of learning by doing and by using involved. This at times entails that the observation of successful outcomes acts as a guide for new biomedical research on the underlying causes of disease. But, regardless of whether scientific understanding is strong or weak, all the case studies in this collection provide ample evidence of strong feedback between adoption and research and development in medicine, whereby new technologies need to be continuously adapted because drawbacks (for example, side-effects) and potential improvements become apparent only through use. Crucially, the way in which both artefacts and practices evolve depends on the exchange of knowledge between clinicians, hospital administrators, patients, insurers and regulators, who influence the rate and direction of medical innovation by explicitly identifying priority needs and redefining modes of service provision.