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.