5. Changing a Conflict of Interest (COI) into a Convergence of Interest (COI)

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5. Changing a Conflict of Interest (COI) into a Convergence of Interest (COI)

“Scientific enterprise is not just a quest for knowledge and truth; it is also a fairly good reflection of the whole spectrum of human behavior: from genius, passion and jealousy, to mistakes and misconduct.”  Cokol and Rodriguez-Esteban….EMBO reports 2008.

In our quest to get more impact from America’s Academic Medical Centers (AMCs) by making innovation and entrepreneurship an expected and natural academic behavior, we need to continue to discuss various system requirements that exist in AMCs that are necessary to process innovation to eventual impact.  One of these system requirements is the declaring of a conflict of interest (COI) and disclosing this to the scrutiny of an institution’s COI committee.  I know…it already sounds confusing, a bit nefarious, and not very fun (as in colonoscopy not fun).  You might be saying, where is the conflict in coming up with an awesome life-saving idea and moving it to the bedside.

First, a small bit of history.  There was once (and unfortunately still is to a significant extent) a practice where medical industry would pay medical key opinion leaders (KOLs) a lot of coin to speak to their medical brothers and sisters about products that the industry entity was producing.  This could be devices, diagnostics, pharma, etc.  Think of it as an endorsement of medical athletic wear by a medical superstar.  What company doesn’t want that?  The problem was that many times the KOLs forgot to… uhhh… mention they were being paid so that the praise they were giving the product was maybe less objective than the audience would have expected.  This also led to problems when KOLs were maybe advocating that their institutions adopt the product or service.  

Well…of course what could go wrong in medicine with this sports analogy of superstars endorsing the life impacting correlations of sneakers (devices), power drinks (therapeutics), etc.?  Sometimes industry would put KOLs on their boards, giving them stock options and more cash, lots of travel (can you say Platinum miles member) and speaking engagements, which further muddied objectivity.  For the most part these KOLs simply gave advice and advocated (we hope) for products they truly believed were transformative, but some of course had other agendas.  

This doesn’t necessarily sit well in the sacred halls of the ivory tower of AMCs so on the eighth day, COI committees were formed, and they were ...well…ok at first.  COI committees were designed to objectively provide some checks and balances remembering that disclosure did not necessarily represent a conflict but perhaps an appearance of conflict that should be overseen making sure that things like reimbursement for these KOL services were not out of proportion to services rendered and that the KOLs were ensuring they were disclosing relationships to the institution, their colleagues, societies, journals, patients (if the KOLs were leading studies for industry) etc.   In fact, societies and journals, IRBs, grant agencies, and others jumped on board and now mandate disclosure if the individual(s) submitting have any real or potential financial skin in the game on the trial, study, or paper they are attempting to undertake or get published.  However, if you are hell bent on gaming and cheating the system, stuff happens.  We had such a rascal at the University of Michigan.  Dr. Sid Gilman, a distinguished Professor of Neurology (classic academic career and superstar), became a bit of a poster-child for what not to do and how all the checks in the world won’t necessarily prevent a problem.    

Ok…so COI committees seem reasonable, but we all know the bureaucracy of the AMC is a bit like kudzu.  It sort of looks all around to see what else it can latch on to and feed off of.   Hey…know what looks COI juicy…a good idea and potentially commercializable product from Dr. Smith (name changed to protect the innocent).  Professor Smith has an awesome idea to develop a device that will help paramedics and doctors save more patients who experience cardiac arrest (there are approximately 350,000 cases of out-of-hospital cardiac arrest with a 90% fatality rate). She works hard to develop a prototype and shows initial proof in her lab that it works.  She then works with her University’s Tech Transfer Office and files a patent to protect the idea and technology.

However, at this stage no established industry partner feels the technology has been sufficiently de-risked or perhaps had a bad third quarter and can’t make the investment at this point.  Dr. Smith, however, feels she and the local entrepreneurial community might be able to leverage some early stage investment and move the technology forward.  She has identified a capable CEO and some pre-seed investment and decides to start an LLC and negotiate a license for the technology from the University.  This act, however, activates an internal red alert of required activities with the COI committee which in turn requires additional steps with the IRBs, review of all other research activities, and other things.  Anything that is faintly connected to this technology (graduate students, future grants, speaking engagements, travel, etc.) will require more and ongoing key strokes.  Sometimes an audience before the COI committee is required.  It can really become hot and heavy if, heaven forbid, the faculty innovator as a company founder or other medical officer takes shares in the company even if its 0.00001 cents/share.  Many times, the innovator-entrepreneur won’t be allowed to be the principal investigator on a clinical study examining the technology. They must also disclose to patient subjects in research consent forms that they are part of a company and may benefit from the results (it really sounds and makes the investigator seem sleazy).  At some institutions and for some individuals, this exercise is simply too much, and I personally know colleagues who simply forgo the opportunity to engage in the entrepreneurial aspects of the enterprise and instead wait for magic to happen in the university’s Tech Transfer Office.   

So, what’s wrong with this?  For one thing, this can significantly suppress innovation and divorces it from the reality of the principles of entrepreneurship (see blog #4).  There’s not a technology fairy that visits innovators in the middle of the night and magically refines and get transformative technologies to market, saving lives and leaving bags of cash at the University for all to enjoy.  Instead, there are these beings called entrepreneurs who must raise piles of cash and risk a lot to take the technology to the next level and the next, and the next to try to get it to market.  In the end, after years of blood, sweat, tears, and cash, the majority are dashed to pieces on the rocky shores of the free market.  Only a very small percentage sail into the harbor of success like a luxury cruise liner impacting the thousands of patients hoped for. Yes…this is the reality innovators and entrepreneurs know about, but AMC leadership and committees have little first-hand knowledge of.  For most of them, optics are the first order of business. 

What makes this disclosure and management process curious is that there is, in my opinion, lack of any semblance of equipoise when applying COI principles to promotion and tenure (P&T…see blog #2) and other activities which can be argued hold much more potential for mischief.  I always found it puzzling that for faculty who are in the process of P&T and are hard pressed to do research and publish (or perish), there is no obligation to disclose to patients they may be enrolling in studies, or journals they are submitting research findings to that the clinical study and publication of this new knowledge are critical to their success and required for their being promoted and/or tenured resulting in their getting significant job security, higher salaries, more power in the institution, prestige, ability to travel and promote their work, etc.  Hmmmm…any conflict here?  Just saying.   If one looked at this objectively, there is really just as much conflict if not more.  In fact, folks...there is likely to be far more potential for scientific misconduct in the timebomb-ticking race for P&T than in the pursuit of commercialization of a technology invented by a faculty member.  

Let’s also not forget the poorly publicly advertised reproducibility crisis facing medicine and science in which an increasing number of studies for which we have paid billions of dollars for from the NIH and other sources can’t be replicated.  And…oh did I mention the significant increase in retracted papers from journals including those with the most prestige?   These should really be targets for the COI kudzu to latch onto. 

In addition to the usual, IRB, journal and grant agency peer review, Dr. Smith will have to convince early investors, venture firms and industry partners of the merits of her innovation.  All of these entities will in turn do their own due diligence, combing over the literature, talking to experts, etc.  And wait…that’s not all…she and her company will have the pleasure of dealing with the FDA and that regulatory stuff.  Dr. Smith, as an entrepreneur has essentially exposed every nook and cranny of her innovation and for that matter, her career for scrutiny putting at risk a lot of people’s time and money and even the safety of patients.  So…you can see that skirting important steps driven by the nefarious motive of profit poses a bit of risk to Dr. Smith. 

The process to get Dr. Smith’s innovation to market to treat victims of cardiac arrest will likely take a decade and millions and millions of dollars.  Over this time, Dr. Smith will face more checks and balances than the traditional academic that ensures she doesn’t try to fool everyone and go all Theranos on us (however, remember Elizabet Holmes was never a member of the Academy).  Malfeasance in the public sector can lead to financial devastation and jail time.  Not so much in the world of academia if you falsify data in a paper.  Maybe Dr. Smith should be allowed to put in the IRB consent form something like:  Dr. Smith was bold enough to form a company to help further develop this potential life-saving technology.  She is working like crazy trying to raise enough money to refine and test it. There is a chance she may be successful over the next decade and might even break even, but in reality, there's less than a 1% chance this will happen.  More likely her dreams will be buried at the bottom of the ocean and more people will continue to die of cardiac arrest.  If you consent to this study, sign here...

So on balance, I would say, if there is a clear and present COI danger, it's not coming from the entrepreneurial class within the AMC.  What I am arguing is that innovation and entrepreneurship that moves ideas to impact involves activities that are, in essence, no different from a COI standpoint than with the traditional activities associated with P&T.  The activities which lead to deserved P&T are expected of faculty hired into AMCs (discovery and transmission of new knowledge, teaching, excellent patient care, etc.).  When that new discovery and knowledge gets transmitted to the outside world it sometimes requires additional activities that transform it to a form that requires entrepreneurship and commercialization.   This is simply a convergence of interest of the faculty innovator and the AMC and not a conflict any more than the previously mentioned traditional P&T activities, which have beneficial consequences not just to the individual faculty member, but also to the institution and the patients it serves.  In other words…both should be considered equally natural and expected.  Heck…the AMC already knows this cause guess what...they are going to take an equity stake in Dr. Smith’s company in addition to getting a royalty rate.  Again…this is not a conflict but simply a real-world essential business reality.  

While this makes great sense to me, I had an opportunity to make this argument several years ago at the Association of American Medical Colleges Focus on Conflict of Interest Academe.  Nice people, a bit of discussion (mostly the push-back kind), but a lot of deer in the headlight looks.  I don’t know what the ultimate answer is. However, I know it should start with more dialogue on the realities of innovation and entrepreneurship, better communication with the public on the process and expectations and how they are actually benefiting, and some attempt to ease the burden or make the COI process more efficient for innovators wishing to engage in entrepreneurship.  

Given all this and if things don’t change…if you are an academic innovator and don’t have a conflict…I would suggest you get one.  Otherwise you might not truly be innovating toward full impact!  Wish this was the ultimate sign of convergence but…just saying it feels like divergence.   I love me some COI.   

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4. Innovation vs. Entrepreneurship in Academic Medicine: It's Not Either Or, It’s And and And!

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4. Innovation vs. Entrepreneurship in Academic Medicine: It's Not Either Or, It’s And and And!

In our quest to make innovation and entrepreneurship a natural and expected academic behavior to accelerate great ideas toward patient impact, we need to talk about barriers that make it difficult for innovators in university-based Academic Medical Centers (AMCs) to engage. I have received feedback both internally and externally (including some outright flack) regarding combining the terms.

A good bit of this has come from traditionalists inside the AMC. For example, many academic scientists feel they are innovating by virtue of making fundamental discoveries, but think of this activity as completely separate and distinct from entrepreneurship. Indeed, they do not feel compelled to think about the transition of this new knowledge into anything other than an outward-facing communication to the world of science (read: publication) or perhaps another grant. Others feel they are producing new knowledge that is innovative and inherently distributive (can be provided broadly to others in many forms to make a difference) but feel they are not entrepreneurs because they have not commercialized that knowledge as a product. In essence, within the university setting, “entrepreneurship” is often separated from “innovation” and many flat out disdain the association of the two.  In fact….Michigan Medicine recently updated its mission statement.  Some of us tried to influence the Research aspect of this mission statement by suggesting that our visionary research will be empowered by creating a culture of high-risk innovators with an entrepreneurial spirit that transforms biomedical discoveries into products and policies with real-world impact. Sounds exciting and something that the public and industry would resonate with…right?  Uh….well apparently this gave some of the committee heartburn and was deemed too much too fast because some thought our basic scientists would not identify with it.  What a bummer! 

Even from outside the university, I have heard from traditionalists in industry (including the startup world and large biotech) who reinforce a lot of this as they, too, see a definitive difference between “innovation” and “entrepreneurship” and suggest that innovators should stay in their own swim lane and do what they do best and allow entrepreneurs to do the same. In short, this reinforces the above notion that the two are necessarily separate, making many innovators within the AMC feel uncomfortable identifying as entrepreneurs. I think this is shortsighted, propagates stereotypes, and produces unnecessary, and even harmful, cultural barriers, especially within the basic sciences.

To be certain, there are differences between hardcore innovators and hardcore entrepreneurs and by and large, there is merit to the argument that those who can do both well are really, really rare (like the Golden Tabby Tiger and Javan Rhino, but not as rare as unicorns).  After all, there can be a difference between great chefs and great restaurateurs, actors and directors, musicians and producers, etc.  There are a few that are great at both: Emeril Lagasse is both a renowned chef and restaurateur (I’ve eaten at all of his New Orleans restaurants – 5 stars), Clint Eastwood is both a great actor and director (I almost named my son Dirty Harry).

In fact, I would submit that if you are a successful basic medical scientist, clinician scientist, medical educator or other researcher motivated by the importance of fundamental discovery, developing new scientific techniques or innovative ways to educate, you are in most cases already engaged in entrepreneurial behaviors! You want your new discovery, newly developed technique, new curriculum, new book, new policy, etc., adopted by others. You have journals, grants, scientific and educational venues, etc., to help you propagate and share your new discovery and message. Some of you are even monetizing these discoveries in the form of promotion and tenure (getting pay raises and job security), notoriety, and awards (travel and presentations), and in getting more grants and resources to let you do more of what you love.

Well, that’s exactly what entrepreneurs want and do as well. Entrepreneurs want discoveries and inventions to be propagated to the masses, in this case through commercial use.

In the AMC, if innovation is like your mom who says to you when your were a kid, “Dream my child, dream big, change the world with your big ideas,” then entrepreneurship is like your dad three years after you have graduated from college and says, “Hey, kid, you can’t just live in the basement all of your life – use those ideas and do something, will ya?” Entrepreneurship is the transition of your innovation into something that propagates and brings continued, sustained value.  

In the end, innovation needs entrepreneurship.

Innovation that does not couple itself with entrepreneurship (at least in spirit) doesn’t make a lot of sense. It would be a practice that is divorced from reality. It would be like making the discovery and then saying, “I am not going to publish or present it.” It’s the same for those developing innovative teaching techniques, policies, or clinical care processes. Truth be told, these discoveries and techniques are products! Your research, discoveries and innovations are platforms for building your professional credibility that will be leveraged for bigger things. There is really no difference in the world of industry where entrepreneurs succeed or fail based on the products they are commercializing.  So in essence, Promotion and Tenure (see previous blogs) is perhaps one of the most entrepreneurial concepts in academia.

So the bottom line is this: You don’t have to call yourself an entrepreneur – you can just say that you have the entrepreneurial spirit (it will be our little secret). I just hope that you take a moment every now and then to think about how you could accelerate the impact of your new research discovery by thinking of it in terms of how it could impact patients sooner as a potential product.  

Hardcore entrepreneurs outside of the AMC would also do well to cede a little ground regarding the definitions of innovation and entrepreneurship. I think the best entrepreneurs are those who understand the process of innovation and even though they are many times not responsible for the idea itself, they encourage and create a culture that promotes continued innovation. Such understanding is essential in making innovation and entrepreneurship a natural and expected academic behavior and a force multiplier for improving human health.

As you may recall in one of my previous blogs…the field of emergency medicine and critical care (my tribe) has little to offer to save your life compared to 30 years ago.  MCIRCC is taking a new approach to change this by developing a culture of high-risk, high-reward innovation that is linked to entrepreneurship and commercialization.  To paraphrase Einstein….the definition of insanity is doing the same thing over and over and expecting a different results!  Let’s try something new shall we!

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3. An Important Innovation PSA to Biomedical Researchers and Leaders: Stay Calm, Innovate, and Make It Relevant!

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3. An Important Innovation PSA to Biomedical Researchers and Leaders: Stay Calm, Innovate, and Make It Relevant!

This is a PSA (public service announcement and not prostate specific antigen).  Lately, there are a lot of academic leaders including university presidents, medical school deans, department chairs, and many others crying out in anguish over possible cuts (or no increases) in federal funding for medical research and/or infrastructure. Federal funding from sources like the National Institutes of Health (NIH) are the lifeblood of medical research at our great universities and academic medical centers (AMCs). At Michigan Medicine, we are no exception. We are fortunate to be the recipients of a lot a federal research funding and big cuts would pose significant challenges.  Recently, we dropped in a couple of notches in our NIH ranking for funding of medical schools despite having increased our overall funding.  Boy…you would have thought we were being foreclosed on.  It was and all hands on deck to develop strategies on who we could improve our rankings. 

However, while we all have our heads on fire about this in our bubble we call academia, I don’t hear any similar outcry from the public. The public generally knows that AMCs provide great care, but they don’t see the research engine running under the hood. Now by the “public” I mean Mr. and Mrs. Middle America tax-payer living in urban, suburban, and rural America. How do I know this and what makes me such a reliable source? Well, my family members and friends span this demographic. They are teachers, accountants, farmers, soldiers, homemakers, etc. Some are physicians and nurses practicing in community hospitals. They live in big cities, small cities, East Coast, West Coast, Gulf Coast, North Coast and everywhere in between. I even know a cowboy or two.

They NEVER ask me if I am funded by the NIH or what I think about budget cuts to the NIH. They never ask me how highly ranked the University of Michigan is in NIH funding or express their frustration that we dropped in NIH rankings like we dropped in our football rankings. They probably don’t even know what the NIH is, or for that matter, what translational research, clinical research, or basic science research is. I know when I have tried to define or explain these things to them they start to drift off and excuse themselves to make a phone call, take out the garbage, or walk the dog (even when they don’t even have a dog).

What they do ask me, and can’t get enough of, is what my latest innovation or company is and what disease will it help cure or improve. Mom or Dad will call and say, “How are things, son, how are the kids, and what’s the latest with that thing-a-ma-jig you were making to stop life-threatening hemorrhage?” A brother or friend calls, “Hey dude, what did you think of the game last night and when can I invest in your company to treat those million cases of sepsis a year?” 

So while I REALLY don’t want cuts to various federal research budgets, I have to be honest: I am not very sympathetic to our cause because, based on my skills as a pollster (as evidenced above), we are not very good at messaging why our research MATTERS to those who are paying for us to do all that research (the ordinary citizen and taxpayer).

Let me be just a little more direct: We stink at the messaging and in public engagement! Even if you are an alumnus from Michigan, you are likely to know more about our football team (not for good reasons) than you are that we invented the Electrocardiogram, Extracorporeal Membrane Oxygenation, FluMist, or a recent breakthrough treatment for Gaucher disease, as well as the plethora of technologies we are working on in cancer, neurodegenerative disease, child health, critical care, and on and on and on. Now at U-M, we regularly celebrate these achievements and pat ourselves on the back frequently (I sometimes get a little sore from doing this), however, this doesn’t help in our bigger challenge.

So, back to the bemoaning of budget cuts and policy changes. It’s our fault. Our message has been “lost in translation.” We are fighting a battle of relevancy and this is made more difficult because we, ourselves confuse rankings, total funding, and other things with REAL IMPACT.  If the public clearly understood what we do and what the consequences of decreased funding would be, those with the purse strings would have serious second, third, and 1010 thoughts about cutting research budgets. Again, by the public, I don’t mean Congress (although that would help). We answer to the public (our current and future patients who send money to the government in the form of taxes), period!

So, how do we message better? OK, bias alert, as an Innovation guy, I’m going to say innovation and not only innovation, but also entrepreneurship and commercialization, which, by the way, creates jobs outside the bubble. A very powerful way to connect the public with our great science and the battles against disease that we are desperately engaged in is through the message of innovation and entrepreneurship. The most powerful way to connect the public with our great research is to make the output of that research directly relevant to them. As I pointed out earlier, this is how those outside my academic bubble connect to what I do. We and our innovation partners around the University are developing and executing on programming and messaging that connects us to the community and teaches our community that innovation and entrepreneurship is and should be a natural and even expected academic behavior.

Now I can hear the groan of the Rembrandt basic science research masters: “Not so fast, sonny-- basic science research can’t be expected to…blah, blah, blah.” If you are all about basic research, fantastic, but there is a translational innovation and potential entrepreneurship story you can, should, and must tell about your work to others outside the bubble. Working on a new cellular pathway or signaling system? The public needs to know what breakthrough it might produce (a new diagnostic, new therapeutic, new diet, etc.). They would be fascinated to learn about the journey, which includes the failures, but mostly about the potential to produce something meaningful for them! So, sprinkle this on your organic yogurt or oatmeal and think about it. Think about what if we messaged in this way all the time to the public, from every researcher (innovator) in every AMC. If we did, we might not be in the position we are in in justifying why cuts or re-engineering of budgets are not in the best interests of the public. Right now, our status quo messaging is not resonating with the public!

In fact, if we message differently, we will be in a better position to negotiate federal research policy or programs in our favor. If we message what we do – our impact– from an innovation and entrepreneurship perspective, we would then be asking, “What are the consequences of any new policy or decision on innovation?” In other words, how difficult will ill-informed decisions made by good-meaning bureaucrats or even public advocacy groups have on our ability to innovate and commercialize products? Heck, when put in that way, both the public and industry would become our informed partners. Right now, our status quo messaging is not resonating with the public!

As I mentioned in my first blog, while defense may win championships in football, it won’t win diddly squat in fighting disease. We need relentless offense. The defense we are up against is disease. What we don’t need opposing us is us. Better messaging and communications strategies, which help the communities we serve view what we do through the lens of innovation and entrepreneurship, will go a long way in developing the clear 20:20 vision we need to secure essential stability in research funding and sound research policy. Like any market, our market hates uncertainty.

We’ll talk in future blogs regarding other specific things we should consider changing in federal programming that could result in potentially disruptive but extremely impactful changes that would further our cause and bring both the public and industry to our sides as team members in the battle against disease and suffering. Let’s quit complaining, stay calm, keep innovating, and spread the message of relevance early and often!

 

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2. The Innovator's 'Academic' Dilemma: A Primer

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2. The Innovator's 'Academic' Dilemma: A Primer

Clayton Christiansen wrote a bestseller called The Innovator’s DilemmaIt’s an awesome and instructive read on why and how new technologies can result in large, established firms failing because they do NOT see the unexpected from potential competitors. The concept of disruptive innovation is also introduced that suggests it is difficult to envision what disruption will occur from technologies in their early state. It’s a bit scary if you are a CEO - like you CEO guys and gals need something else to worry about. I hope to be able to engage Mr. Christiansen in a future blog or podcast in the future. Clayton, buddy, if you’re out there reading this, give me a call to schedule!

Today’s post is about setting the stage in explaining why it’s such a !@#$*&% difficult choice (dilemma) for faculty at our great academic medical centers (AMCs) on whether or not to devote significant energy and resources toward innovation, commercialization and entrepreneurship. In future posts, I’ll cover, in greater detail, definitions of innovation, including disruptive innovation, as well as entrepreneurship as it applies to academic medicine; for today, let’s just broadly define innovation as an idea to change the way we do something in medicine that requires investment and risk. The investment and risk can be time and money or a combination of the two.

While this post is not going to tell any of the folks struggling with biomedical innovation in academic medicine anything new (you peeps can skip to the next blog), it will be a primer for our industry, entrepreneurial and other interested colleagues that hopefully helps you understand why things can move so damn slowly within the academic sphere (bubble) or why you often can’t get good academic partnership traction.

Not to get too much in the weeds, but individuals enter the field of academic medicine (apply for, get recruited to, etc.) because they have certain talents that fit the traditional AMC model. Let me explain. For example, they are clinicallygifted (can transplant a heart and liver in two different patients at the same time), are great teachers(can mind-meld with students like Mr. Spock), or are great researchers(ask great questions that the National Institutes of Health cannot resist in funding for 20 years with no expected answers or solutions) or combinations of all of these. In academic medicine we call this the tripartite mission…excellence in patient care, research, and teaching.

Quantifying the value of these activities is pretty simple. If you are valued for your clinical expertise, then how much clinical revenue you produce for your expertise, reputation, and outcomes in patient care is measured ($$$). If you’re a great researcher, it’s about how much grant funding you receive from prestigious sources like the NIH (especially the NIH) and how many papers you publish in highly ranked journals.

If you are a real Socrates as a teacher, then trainee evaluations are used to see how you measure up. If you are charged with a combination of these activities, then there is a mix and oh, by the way, most everyone has some additional administrative duties they are assigned and evaluated on, as well. Those clinician-scientists doing a really fab job are called a “triple threat” (watch out Vin Diesel, there might be an academic sequel to “XXX”). Basic medical scientists, while not caring for patients, are responsible for a huge proportion of discoveries in our medical schools and they focus on research as well as teaching of medical and graduate students (“dual threats” but still deadly!). Each of these activities are funded in large part through either tuition, clinically generated revenue, or research dollars. Each carries a specific value to the AMC which in many cases has added challenges in generating sufficient margins to reinvest in its operation for its clinical, research and teaching missions (certainly a challenge given fluctuating uncertainties in health care, research, and education). Each is also easy to track from a return standpoint (clinical revenue, grant revenue, tuition revenue, etc.). Lots of these medical schools and medical centers are state institutions and receive various levels of annual support, which, of course, can fluctuate based on a state’s economy…another challenge.

The culmination of how well we perform these duties determines how we move up or fall off (ouch) the professional ladder in academic medicine. This process is called promotion and tenure (P&T, for short) and forms the ranks of instructor (lowest rank), to assistant professor, associate professor and full professor (highest rank). Tenure is a state of permanent appointment that requires extraordinary circumstances (really bad personal, professional, or financial behavior) to result in termination. While many believe this is an outdated concept, tenure is the coveted position that rising stars in academia aspire to (by the way, I am a tenured full professor…ah, it feels so good!). There is another important thing to know: For the tenure track, there is a limit to the time one can take to advance to the next level. A ticking clock (or time bomb, if you will) usually begins at the rank of assistant professor and you typically get about seven years to advance to an associate professor with tenure. If you don’t succeed, you are voted off the island and have to move on, making your chances of getting another shot at climbing the tenure ladder at another medical school about as good as climbing Mt. Everest in your underwear without a Sherpa (in other words, not that good). Most medical schools and university-based AMCs have this hierarchy and process.

Why is the above information important to understand? There are certainly enormous opportunities to innovate (even disruptively) within the tripartite mission of activities that we in academic medicine are charged with. A major challenge is how to pay for it using two different currencies, money and time, which have huge impacts on the bottom line of AMCs. As a whole, innovation in medicine takes time and is not, in general, easy to fund through traditional grant sources (NIH) or reallocation of time. In other words, the horizon for the return on investment can be much longer than the traditional activities that those in academic medicine get paid to do. If the talented surgeon is not in the operating room performing complex surgeries, then clinical revenue is reduced. If researchers are not bringing in grants to support their salaries and those of their assistants, then resources have to be found to bridge the research. If you need a break from teaching, then a replacement has to be found.  All in all, in the AMC, time is actually money. Now, while those who have successfully climbed the promotion and tenure ladder have more flexibility in their time and choices, our youngest and brightest down the ladder struggle with deviating to do anything that changes the traditional calculus that might jeopardize their career path. Innovation and commercialization activity is deemed just too risky because we cannot be certain of its power and return on investment in a time frame we are used to working within--it’s a DILEMMA!  This has me really worried in regards of our future ability to create the impact we need as young faculty are in the best position to have eureka moments.  Many of us who have been researchers or clinicians for so long actually become blinded by our experience and long-term exposure to our environments, unable (or unwilling) to recognize new opportunities.

Just to be fair, there are also external reasons (not good) that are in part responsible for why medical schools and academia can unknowingly (or knowingly) suppress innovation. We will open those cans of worms in the future. While the above is a bit simplistic, it will give us a common starting place for future discussion.

Now, I don’t want you to think that all is hopeless. Part of the solution is re-engineering culture and incentives that allow a convergence of innovation and entrepreneurship activities as extra dimensions of the traditional tripartite mission. In future blog posts, we will explore what we and others have done and are doing to bend the rules (its can be pretty naughty but fun) or change the game in order to make innovation and entrepreneurship both a natural and expected academic behavior. Without such strategies, we won’t be getting the impact our patients need and deserve from our AMCs and universities.

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