As a community, we also make decisions to resist particular innovations. Rogers' classic work The Diffusion of innovations is filled with examples of the barriers that any innovation must cross before it comes into common use [2]. Among the greatest of these barriers is the culture of organisations and societies, because it is within cultures that we decide what is valuable and what is not. Thus, in medicine, if a new technology is seen to threaten our role as doctors or to diminish our importance, then it is likely to be resisted. If our peers scorn the use of a particular technology, or favour another, then we are more likely to follow suit. So, our culture shapes the technologies we build and the technologies that we adopt.
One of the problems facing practising clinicians is that much of the technological innovation is coming from outside our own professional culture. It is hard not to feel deluged by the offerings of the pharmaceutical, biotechnology and information industries. Why is the situation not reversed? What is it about the clinical culture that makes us predominantly adopters of, rather than innovators of, technology?
If we scan the pages of our medical journals, we see that much of clincal science revolves around assessing the "evidence". Somehow, whether consciously or unconsciously, clinicians have assumed the role of gatekeeper, vetting the creations of others. But before a drug or technology comes to randomised clinical trial, there has been a long and expensive path of invention and experimentation. Indeed, this hidden process of innovation applies to most technologies, where probably only one in ten ideas makes it off the drawing board and into an applicability trial.
When others are better equipped than clinicians to do the inventing, the system works well. When clinicians are faced with challenges that require us to be the inventors, we run into trouble. We are very good at being critical and analytical, but are not used to being lateral, fuzzy and playful in our thinking. New ideas require nurturing, cajoling and bending and can easily get crushed if we prematurely apply our skills of critical evaluation. Yet it is this creative and necessarily fluid process of innovation that is desperately needed today. Struggling with an ever more burdened healthcare system, we know we must re-invent the way we work, and redefine our roles and the way that we structure the delivery of care. To do this, we will need to be as innovative as we are critical.
Unfortunately, the healthcare culture shares many of the attributes of large organisations that struggle with, or fail to adapt to, change. In common with many other established organisations, the success of the existing way of doing business makes the cultural norm one of steady, incremental change rather than radical change. Further, the older the organisation, the richer are the interdependencies between groups in that organisation [3]. If one or more small groups are threatened by an innovation, its passage through the larger organisation is likely to be stifled. Indeed, those who study the interactions between professional subcultures within healthcare consider the conflicting beliefs of these different groups to be a major barrier to health reform [4].
If we look to the strategies of enduring organisations that successfully adopt innovations, we see a willingness to recognise that change is essential, and an ability to relinquish old hard-won skills and ideas in favour of the new. Such organisations have the skills to create a vision of what they wish to become, and to set about making that vision come true. The process of continuous renewal is one of seeking advantage in change, and of finding new evolutionary niches in the changing competitive landscape.
So, if healthcare is to evolve in pace with the rest of society, it needs to focus on creating a sustainable and flexible culture that does not fear innovation. Whether we are enraptured by the promise of technology, or are in fear of it, simply being reactive to its development is not appropriate. Our culture's beliefs and values shape what we create and what we dream. An anti-technology stand leaves us room only to react to what is done by others, and, with the potential to innovate accelerating as it is, now is the time to be pro-active.
Many of us believe that medicine will be profoundly transformed in this coming generation, and that our power to build new technologies will be pivotal in engineering that transformation. But it is not the technology that will transform medicine -- it is our vision of medicine that will define the change. Our skills of invention will then shape the technology we need to make the vision reality.
