I have recently been reading about the history of obstetrics, or a small part of it. This was not out of some arcane interest in the history of medicine but because I was reading a column written by a US surgeon called Atul Gawande in the New Yorker.
The article detailed some of the history of obstetrics, including how forceps came to be invented by a French man called Peter Chamberlen in the 17th century. The Chamberlen family went on to keep forceps a secret for three generations before passing it on to a Dutchman, Roger van Roonhuysen, who kept them in his own family for a further 60 years. The widespread acceptance of forceps did not occur until the 18th century, when their secret became public knowledge.
While interesting, it was not this fact that piqued my interest, but the question of why the history of obstetrics might have ramifications for improving the provision of care in other areas.
In the 1930s one in 150 pregnancies ended in the mother's death. This fell to one in 2,000 by the 1950s but although outcomes for mothers had dramatically improved over the previous two decades, one in 30 babies still died at birth.
All this was to change over the coming decades due in large part to a doctor working in New York called Virginia Apgar.
Apgar was an anaesthesiologist who was appalled at the care newborn babies received, so she devised a score that would allow nurses to quantify the conditions of new born babies.
The score could be a maximum of 10 and comprised five components. There were two points each for: being pink all over, crying, good vigorous breathing, moving all four limbs and a heart rate over 100.
Ten points indicated a child born in perfect health, four or less a blue, limp baby.
The score changed the way babies were delivered from an unquantifiable experience to one where there was a measured outcome that was recorded at one minute and five minutes, with data collected and observations made.
Over the years after its publication in 1953 the score drove a continued improvement in the outcomes of newborn babies. It indicated that spinal and epidural anaesthesia resulted in better scores than general anaesthesia and that measures such as warming and oxygen could transform a score from minute one to minute five.
Today we are bombarded with studies that advocate one treatment over another and where practices are to be standardised they must be 'evidence based' and so on and so forth. The explanation for not doing something, or the variation in how something is done, is that there is no evidence available as to the efficacy of a specific practice.
The Apgar score, however, was not the result of a double blind randomly controlled clinical trial but the product of experience and observation and showed that by doing something differently things could be improved.
Obstetrics have continued to innovate, improve and implement without necessarily waiting for a trial to demonstrate whether a new practice is a good idea, and the Apgar score is simply one example of this.
This example demonstrates that changes can be made that fundamentally alter the way we work and improve the care that is provided. Where possible, we should encourage, foster and create an environment in which innovation, problem-solving and improvement are endemic. This requires an environment where it is acceptable to experiment and try new things.
While trials are essential to demonstrating and evidencing best practice, there are processes that we could improve through pilots and experimentation without requiring them to demonstrate that doing something a different way would result in better outcomes.