Knowledge is the Enemy of Innovation

“Knowledge is the Enemy of Innovation"

-          Christian Gerber, 8th Annual Meeting of the Codman Shoulder Society

Dear CSS Colleagues:

I often wonder, and perhaps you do as well, why I am sometimes bored with presentations at many academic meetings. While we all have our beliefs and opinions, most of these are based on past studies that are underpowered and not particularly based in strong evidence. I am guilty of this as well in my own presentations and publications.

I was recently reading a book that has nothing to do with orthopedic surgery. In Chapter 14 of his book, Outlive: The Science and Art of Longevity, Peter Attia, MD references a Nobel Laureate on the question of knowledge vs. curiosity (see below):

Dr. Attia goes on to bring up the Dunning-Krueger effect: The Dunning–Kruger effect is defined as the tendency of people with low ability in a specific area to give overly positive assessments of this ability.” If you’re like me, you may be unfamiliar with this concept…and I am not suggesting that any of my colleagues and I are of “low ability”. Quite the contrary, I think it is a question of living in a comfort zone of low evidence and the belief that what we know is 100% so. This may be similar to our faith in religion, as stated above by Richard Feynman.

So, let’s consider the Dunning-Krueger effect and relate this to us as orthopedic surgeons:

When we enthusiastically absorb information from articles, textbooks, lectures, and our own studies, we are sure that what we know is absolutely true (A). If we have sufficient self-awareness and discipline to question our own beliefs, we realize our knowledge is at least 50% wrong (B). Only then do we discern the valuable and rare evidence from some of our peers that leads us to question what we know and focus more on the questions than the answers. “Expert” is probably the wrong term for what we may aspire to become (C). We simply become more informed physicians and surgeons who look for the questions yet to be answered.

In retrospect, I present my own journey below. I initially believed I was an expert and that what I said from the podium was absolutely true. I have come to know better by watching some of my colleagues who, I realized, were always asking if what they believed was true.

So, who are those who I believe have been the ones that follow the Dunning-Kruger effect to their maximum potential? Here are a few of the rare individuals who focus more on the questions than the answers and tend to question their own beliefs. There are many more than these, but these are some that come to mind for me who I believe warrant mention: (see below)

EA Codman: The father of measurement, “The End Result” concept.

Christian Gerber: The discovery of isolated subscapularis tears, the analysis of biomechanics and pathology of rotator cuff tears, the application of tendon transfers to the shoulder to treat irreparable rotator cuff tears, the identification of acromial morphology as a pathoanatomic factor in posterior instability.

Gilles Walch: The concept of anatomical arthroplasty, the identification of glenoid morphology in osteoarthritis, the development of virtual reality planning for shoulder arthroplasty.

Pascal Boileau: Collaboration with Walch on above, also development of BIORSA in reverse shoulder replacement.

Laurent Lafosse: The arthroscopic innovation of nerve surgery.

Lanny Johnson: Development of the motorized shaver for arthroscopy, the first arthroscopic instability surgery.

William H. Harris: The creation of highly cross-linked polyethylene, which extended joint replacement durability.

Reinhold Ganz: The concept of hip joint preservation, which led to arthroscopic procedures to preserve the hip prior to and prevent the development of osteoarthritis.

Alain C. Masquelet: Discovery of reconstruction of soft-tissue and bone defects using biologic potential of the patient’s own tissue.

The last two individuals are the first to win the prestigious Dominik Meyer Award which is the closest thing we have to a Nobel Prize in orthopedics.

So, none of this is really new to others who might be added to the illustrious group above. In his lecture entitled “What Drives Scientific Creativity and Innovation?” at the 8th annual Codman Shoulder Society Meeting last year Christian Gerber pointed out the following:

-          “Medical knowledge has been expanding exponentially. Whereas the doubling time was an estimated 5 years back in 1950, it accelerated to 7 years in 1980, 3.5 years in 2010, and a projected 73 days by 2020.” (according to a 2011 study in transactions of the American Clinical and Climatological Association)

-          Unfortunately, “50% of this knowledge is new & 50% is disproving old knowledge.”

-          For example, “We “knew” that all rotator cuff tears are caused by subacromial impingement.” And many years before this, “we “knew” that the earth was a flat disc.”

-          Dominik Meyer, a brilliant and promising innovator stated the obvious that we should all consider: “the fact that we know something does NOT mean it is true.”

-          Reinhold Ganz said, when he accepted the first Dominik Meyer award for lifetime innovation, “Brilliant people are not eager to learn. They are eager to understand.”

The great Harvard Business School professor, Clayton Christensen, identified the 5 key behaviors of true innovators (“The Innovator’s DNA”):

o   Questioning to "puncture the status quo". 

o   Observing "with intensity beyond the ordinary".

o   Networking to create diverse connections.

o   Experimenting, which is central to innovation.

o   Associational thinking by linking ideas not directly related.

All the individuals I show above in the Dunning-Kruger curve are defined by these five principles. I would ask each of you to consider these as you listen to presentations at academic meetings and formulate your own ideas based on evidence to decide what you do to help your patients.

Finally, Mohit Bhandari, the next Editor-in-Chief of the JBJS, said the following at the 3rd Annual Codman Shoulder Society Meeting in 2016:

-        “The majority of what we’re doing is incremental and does not move things forward. But big innovations happen with the simplest ideas, in which everyone buys in.”

-          “Science is 99% failure, and that’s an optimistic view.” (Robert Leftkowitz, 2012 Nobel Prize)

-          “You can create knowledge, and you can disseminate it. “Evidence does not cease to exist because is it ignored.” (Aldous Huxley)”

-          Fragility: “In summary: small studies risk erroneous conclusions, and we need larger studies. By design, these will require collaborative efforts, and then if you want to go from good to great, you’ll go from successful (footprints on individuals) to significant (footprint on society).”

-          “When the N is big, the problem in question becomes simpler.”

Perhaps I have irritated some of you. That’s great…it will cause you to question what you choose to believe when you attend the next academic meeting.

Kind Regards,

Jon “JP” Warner, MD

Founder, The CSS