Medical Black Swans

A wild black swan Cygnus atratus . taken in so...

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Anyone interested in learning more about the financial meltdown should check out Nassim Taleb’s book The Black Swan.  Published in 2007, it’s message makes the events of 2008 more understandable.  Taleb describes how “predicting the past” by using mathematical models to estimate the future can go very wrong.  When unforseen and unpredictable events, so called “Black Swans” appear, they render all such models useless.

What is the medical connection?  Often we think of medical breakthroughs as the result of carefully directed top-down research carried out in elite institutions.  Though such work does result in many advances, they often are building upon other discoveries which were made quite by accident; medical Black Swans.  Three developments immediately came to mind, and there are certainly far more.  Each is recent, occurring within the past several decades, and none the result of top-down research.

The discovery of penicillin
Antibiotics are ubiquitous today, but they have only been in regular use for about the last 60 yrs or so.  Alexander Fleming’s 1928 chance discovery of mold inhibiting bacterial growth was the spark that led to the antibiotic era in medicine.  Others had noted similar effects in prior decades, and Fleming did not bring penicillin into production.   But his discovery set events in motion that saw antibiotics in widespread use by the mid 1940’s.

The role of Helicobacter Pylori in peptic ulcer disease
In the late 19th and early 20th centuries, it was noted that there was a particular type of bacteria found in the stomach linings of patients with peptic ulcers, gastritis and gastric cancer.  A causative relationship between these bacteria and these disorders was not established until Drs. Barry Marshall and Robin Warren demonstrated it in 1982.  Doing so changed the paradigm of this field,  and transformed the management of peptic ulcer disease.  Prior ulcer treatments consisted of dogmatic behaviors (drinking milk and avoiding spicy foods and stress), and various surgical procedures.  Today, antibiotics are used to eliminate the bacteria and the role of surgery has been greatly diminished.

There were efforts in the early 20th century towards laparoscopy, mainly involving veterinary applications.   The technology was gradually improved, and gynecologists were the first specialty to perform laparoscopic procedures on a routine basis.  It was a German surgeon (Kurt Semm) who performed the first laparoscopic appendectomy.  Rather than being heralded as achieving a breakthrough, he was nearly disciplined for “unethical behavior” by the medical establishment.  Once this technique was applied to gallbladder removal (and surgeons had proceeded up the learning curve), cholecystectomy was transformed from a surgery with a  substantial recovery into one that can sometimes be done on a same-day basis.


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