What does it take to change the game?

retinaWhen is a good idea truly revolutionary? The Oxford English Dictionary defines a game-changer as ‘an event, idea, or procedure that effects a significant shift in the current way of doing or thinking about something’.

If you came back to medicine after a sleep of – let’s say 10 years – you’d find some crucial aspect of practice had changed in a way you would not have predicted. All your colleagues would be thinking differently. You would be obliged to learn to do things differently.

I recently wrote about self-refracting spectacles. They were an innovative idea for patients with acuity problems in poor countries, bypassing the need for refraction by scarce optometrists before glasses can be prescribed. But they haven’t caught on.

Some good ideas just don’t: colour-coding asthma inhalers is common sense, but only a few countries have adopted it. Others don’t fulfill their initial promise: direct thrombin inhibitors such as dagibatrin aren’t proving sufficiently better than warfarin to change the anticoagulation game. Other innovations improve an existing game rather than changing it: surgical checklists save lives because they promote the discipline to follow established good practice. Same game, better play.

Most people would list penicillin, joint replacement, the Pill and intraocular lens replacement for cataracts as game changers. And it was immediately obvious what a difference they would make.

But it can take time for some ideas to be adopted. In 1847 Ignaz Semmelweis proposed that deaths from puerperal fever could be reduced if doctors washed their hands between patients. But doctors resented criticism of their practice, and it wasn’t until well after his death in an asylum in 1865 that his idea was accepted and maternal deaths finally fell.

Even now it can take a long time to turn the ship around. Despite sound evidence that administration of steroids to women threatened with premature labour matures the foetal lungs and greatly reduces the mortality from respiratory distress syndrome, a lot of babies died before it became standard practice.

Game-changers often mean rethinking tried and trusted ways of doing things. Clipping intracranial aneurysms used to be neurosurgeons’ fun operation, but when trials of endovascular coiling were published, they recognised that embolisation by neuroradiologists is safer and more effective.

Not surprisingly some surgeons didn’t reckon endoscopic surgery was here to stay. They could remove abdominal organs neatly in no time through a generous incision, and were perhaps too old to learn new tricks. But the advantages for patients, and a generation of surgeons trained in keyhole techniques, changed the game. Over the years to come, will da Vinci change surgery as decisively as Leonardo changed art? If it becomes economically realistic for surgeons in Birmingham to use robots to operate on patients in Burundi, perhaps yes.

Commercial vested interests may obstruct change, and political vested interests, too. Medical use of marijuana may be a game-changer for some patients, but politicians who have campaigned on the evils of cannabis are slow to accept that idea.

There’s a recent development on the funny glasses front, and it might just change that game. Peek is an app and a cheap but clever gizmo which clips onto your smartphone and turns it into a comprehensive eye exam tool. It was developed by a British trio: an ophthalmologist, an engineer and a software geek. With PEEK on your phone you can check for cataracts, refract, and take a high resolution image of a retina. You can show the patient how the world looks to them compared with someone of normal vision. If you don’t have phone reception, the information is stored till you can send the images back to ophthalmologists anywhere. Low cost, a little training, one person on a bike.

And what game-changers are on the horizon?

Gene therapy is already offering extension of life to some cancer patients but it isn’t quite a game-changer – yet. 3D printing is in its infancy but seems likely to find a staggering range of applications. It’s already used to create tailor-made synthetic prostheses for joint replacement and replacing bone deficits such as sections of skulls. Surgeons are using 3D modelling to plan and practise tricky operations, for example where the normal anatomy has been destroyed by tumour. ‘Printing’ your pills from a digital prescription, particularly useful for individualized drugs such as gene therapy, is on the horizon. The possibilities of combining with tissue engineering, scanners and 3D printing are being explored to ‘print’ customised heart valves, skin, intervertebral discs, kidneys – in future it may be possible to create any soft tissue organ from the patient’s own cells, radically changing the transplant game.

These technologies are certainly revolutionary, even if only the wealthy will be able to upgrade all their worn body parts. True, 3D printing could permit poor countries to use recycled plastic to print small items which can be difficult to get hold of; splints perhaps. But that assumes they have the printer, the power to run it and the bits to keep it running and repair it. 3D printing technology doesn’t sidestep problems of corruption and bureaucracy.

Only with the right context will a good idea translate into a game changer. Few go viral: for better or worse change takes time.

What might change the general practice game? Small technical things, pulse oximeters for instance, change some moves in the game. And while we’re waiting for 3D printing, how about an old-fashioned 2D printer that works reliably throughout a busy surgery?

Game changers don’t have to be technological. What about half hour consultations? That’s short by private practice standards, but would be a luxury for NHS GPs and their patients. Imagine having the time to explore the patient's real concerns, to educate and explain, to consider properly with the patient how to manage the problem. More patients would leave feeling cared for, with a plan they were committed to following, and no need to return dissatisfied. Now that could really change our game.

First published in The Sessional GP magazine.

Judith Harvey

Judith Harvey was a research scientist, ran the VSO programme in Papua New Guinea and taught in a Liverpool comprehensive school before going to medical school. She has been a partner, a salaried GP and a locum, an LMC chair and a long-time supporter NASGP. Her charity, Cuba Medical Link, enables medical students to go to Cuba for their electives.

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