Science.
The very word for many of you conjures unhappy memories of boredom
in high school biology or physics class.
But let me assure that what you did there
had very little to do with science.
That was really the "what" of science.
It was the history of what other people had discovered.
What I'm most interested in as a scientist
is the "how" of science.
Because science is knowledge in process.
We make an observation, guess an explanation for that observation,
and then make a prediction that we can test
with an experiment or other observation.
A couple of examples.
First of all, people noticed that the Earth was below, the sky above,
and both the Sun and the Moon seemed to go around them.
Their guessed explanation was that the Earth must be the center
of the Universe.
The prediction: everything should circle around the Earth.
This was first really tested when Galileo got his hands
on one of the first telescopes,
and as he gazed into the night sky,
what he found there was a planet, Jupiter,
with four moons circling around it.
He then used those moons to follow the path of Jupiter
and found that Jupiter also was not going around the Earth
but around the Sun.
So the prediction test failed.
And this led to the discarding of the theory
that the Earth was the center of the Universe.
Another example: Sir Isaac Newton noticed that things fall to the Earth.
The guessed explanation was gravity,
the prediction that everything should fall to the Earth.
But of course, not everything does fall to the Earth.
So did we discard gravity?
No. We revised the theory and said, gravity pulls things to the Earth
unless there is an equal and opposite force in the other direction.
This led us to learn something new.
We began to pay more attention to the bird and the bird's wings,
and just think of all the discoveries
that have flown from that line of thinking.
So the test failures, the exceptions,
the outliers, teach us what we don't know
and lead us to something new.
This is how science moves forward. This is how science learns.
Sometimes in the media, and even more rarely,
but sometimes even scientists will say
that something or has been scientifically proven.
But I hope that you understand that science never proves anything
definitively forever.
Hopefully science remains curious enough
to look for
and humble enough to recognize
when we have found
the next outlier,
the next exception,
which, like Jupiter's moons,
teaches us what we don't actually know.
We're going to change gears here for a second.
The caduceus, or the symbol of medicine,
means a lot of different things to different people,
but most of our public discourse on medicine
really turns it into an engineering problem.
We have the hallways of Congress,
and the boardrooms of insurance companies
that try to figure out how to pay for it.
The ethicists and epidemiologists try to figure out how best
to distribute medicine,
and the hospitals and physicians are absolutely obsessed
with their protocols and checklists,
trying to figure out how best to safely apply medicine.
These are all good things.
However, they also all assume
at some level
that the textbook of medicine is closed.
We start to measure the quality of our healthcare
by how quickly we can access it.
It doesn't surprise me that in this climate,
many of our institutions for for the provision of healthcare
start to look a heck of a lot like Jiffy Lube.
(Laughter)
The only problem is that when I graduated from medical school,
I didn't get one of those little doohickeys
that your mechanic has to plug into your car
and find out exactly what's wrong with it,
because the textbook of medicine
is not closed.
Medicine is science.
Medicine is knowledge in process.
We make an observation,
we guess an explanation of that observation,
and then we make a prediction that we can test.
Now the testing ground
of most predictions in medicine
is populations,
and you may remember from those boring days in biology class
that populations tend to distribute
around a mean
as a Gaussian or a normal curve.
Therefore, in medicine,
after we make a prediction from a guessed explanation,
we test it in a population.
That means that what we know in medicine,
our knowledge and our knowhow,
comes from populations,
but extends only as far
as the next outlier,
the next exception,
which, like Jupiter's moons,
will teach us what we don't actually know.
Now I am a surgeon
who looks after patients with sarcoma.
Sarcoma is a very rare form of cancer.
It's the cancer of flesh and bones.
And I would tell you that every one of my patients is an outlier,
is an exception.
There is no surgery I have ever performed for a sarcoma patient
that has ever been guided
by a randomized controlled clinical trial,
what we consider the best kind of population-based evidence in medicine.
People talk about thinking outside the box,
but we don't even have a box
in sarcoma.
What we do have as we take a bath in the uncertainty
and unknowns and exceptions and outliers that surround us in sarcoma
is easy access to what I think are those two more important values
for any science:
humility and curiosity.
Because if I am humble and curious,
when a patient asks me a question,
and I don't know the answer,
I'll ask a colleague who may have a similar albeit distinct patient
with sarcoma.
We'll even establish international collaborations.
Those patients will start to talk to each other through chatrooms
and support groups.
It's through this kind of humbly curious communication
that we begin to try and learn new things.
As an example, this is a patient of mine
who had a cancer near his knee.
Because of humbly curious communication
in international collaborations,
we have learned that we can repurpose the ankle to serve as the knee
when we have to remove the knee with the cancer.
He can then wear a prosthetic and run and jump and play.
This opportunity was available to him
because of international collaborations.
It was desirable to him
because he had contacted other patients
who had experienced it.
And so exceptions and outliers in medicine
teach us what we don't know, but also lead us to new thinking.
Now very importantly,
all the new thinking that outliers
and exceptions lead us to in medicine
does not only apply to the outliers and exceptions.
It is not that we only learn from sarcoma patients
ways to manage sarcoma patients.
Sometimes, the outliers
and the exceptions
teach us things that matter quite a lot to the general population.
Like a tree standing outside a forests, the outliers and the exceptions
draw our attention
and lead us into a much greater sense
of perhaps what a tree is.
We often talk about losing the forests for the trees,
but one also loses a tree
within a forest.
But the tree that stands out by itself
makes those relationships
that define a tree,
the relationships between trunk and roots and branches,
much more apparent.
Even if that tree is crooked
or even if that tree
has very unusual relationships between trunk and roots and branches,
it nonetheless draws our attention
and allows us to make observation
that we can then test in the general population.
I told you that sarcomas are rare.
They make up about 1 percent of all cancers.
You also probably know that cancer is considered a genetic disease.
By genetic disease, we mean that cancer is caused by oncogenes
that are turned on in cancer
and tumor suppressor genes that are turned off to cause cancer.
You might think that we learned about oncogenes
and tumor suppressor genes from common cancers
like breast cancer and prostate cancer and lung cancer,
but you'd be wrong.
We learned about oncogenes and tumor suppressor genes
for the first time
in that itty bitty little one percent cancers called sarcoma.
In 1966, Peyton Rous