Balancing Disruptive Innovation and Incremental Progress in Medicine

The entrepreneur and process methods -- two ways of dealing with the problems created by a business segregated into extreme phenotypes


How can I change the world? I ask myself this question every day. It's the standard against which I measure myself, and seek to calibrate success. I admire those who've achieved this, and reserved my greatest admiration for those who try. And I know I'm not alone. Recently, however, I've started to wonder whether by glamorizing the Next Big Thing, I -- we -- have undervalued the importance and the impact of the day-to-day. Have we glorified the virtue of unrestrained ambition while minimizing the worth of structured effort?

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Let's begin with a story I first heard from the late Dr. Judah Folkman, a surgeon and pioneering medical researcher at Harvard. Folkman explained his mission by telling the tale of a man, our protagonist, who was walking by a river when he heard someone call out for assistance mid-stream; immediately, a passer-by jumped into the water to rescue the drowning person. A few minutes later, another drowning person called out, and again, a passer-by jumped into and rescued him; it happened a third time as well. At this point, our protagonist, who had been carefully observing the successive rescue missions, started to walk purposefully upstream. "Where are you going," one of the rescuers cried, dripping wet. "Aren't you going to help save these struggling swimmers?" To which our protagonist replied, "I am: I intend to find out who's throwing them in."

Through this parable, intended to highlight the role of the inquisitive physician, Folkman captured the ambition of medical research perfectly: to understand the fundamental basis of illness and use this knowledge to transform medical practice. It seems like a dead-on description of just the sort of disruptive innovation (PDF) Clayton Christensen describes.

Arguably, most current pharma leaders aren't disruptive thinkers, but careful, deliberate, incremental ones.

I've always found this ideal incredibly compelling; the people I've most admired and wanted to emulate growing up were just these sorts of medical researchers, seeking to use basic knowledge to drive transformative change. And in some cases, these investigators, including Judah Folkman, have been remarkably successful -- they set out to revolutionize medicine and succeeded.

Over time, however, I've developed both a greater skepticism of the transformative potential of much of the basic research that I've seen as well as a deeper appreciation for the people who are actually jumping in the water day after day to rescue the drowning swimmers. If you were to add up the contributions of the two groups over the course of a career, I suspect most of the ambitious physician-scientists I know will wind up contributing only marginally (at best) to the practice of medicine, while the clinicians will have steadily (if perhaps incrementally) impacted thousands of lives.

The familiar partitioning in medicine into those who set out to change the world and those who aim to perform their daily tasks with excellence seems intrinsically unhealthy, and to the extent that the medical community has implicitly endorsed this mindset (perhaps as a consequence of what geneticist Richard Lewontin famously described in the New York Review of Books as our fetishization of DNA, and by extension molecular medicine and the reductionist approach in general), it has contributed to the problem.

Historically, many of the most important innovations, inside and outside of medicine, have not come from a separate class of researcher-kings, but rather from the men and women in the arena, and in particular from clinicians struggling to understand and help the patients in front of them -- something Folkman himself (a practicing surgeon for most of his career) keenly appreciated.

Perhaps, as medicine recognizes the limitations of the preclinical models, and returns the focus of medical science to the patient (see here and here), we will look with greater respect upon those physicians who've never left the bedside -- and we'll work intensively to find ways to leverage their knowledge and share the benefits of their experience.

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The tension between self-conscious innovators and incremental executors pervades the business world as well. We tend to embrace the innovators -- the entrepreneurs -- of course, and thrill to their narrative. I certainly do. But as David Brooks has pointed out in a 2009 op-ed I've often cited and continue to wrestle with (mostly because I believe it's correct but wish it weren't), most successful business leaders aren't disruptive thinkers, nor are they compelling, self-aware protagonists. They're meticulous, methodical, detail-oriented people who seem to genuinely embrace process and highly-structured thinking: I seriously doubt most entered business to make a dent in the universe, but rather because they found a business function they enjoyed, and an environment in which their particular attributes were recognized and rewarded.

Arguably, most current pharma leaders aren't disruptive thinkers, but careful, deliberate, incremental ones; while many critics have blamed this leadership style for the many challenges the industry faces, I've started to wonder if you could construct an equally powerful argument that this careful, incremental thinking has also permitted the industry to continue to survive financially in the near-absence of any profound, disruptive innovation, and in a global environment that's increasingly sensitive to rising health care costs.

I suspect that, just as in medicine, the distinction between deliberate innovator and dutiful incrementalist may be overstated in business as well. While we celebrate (as we should) the self-described entrepreneurs, we may not give adequate credit to those who've managed to get a large organization to pivot in a useful and impactful fashion -- and pivot not because these leaders were determined to change the world, but because it seemed like the right business decision at the moment.

Presented by

David A. Shaywitz, MD, PhD, is a director of strategic and commercial planning at a biopharmaceutical company based in San Francisco, and the co-author of Tech Tonics: Can Passionate Entrepreneurs Heal Healthcare With Technology? More

Trained as a physician-scientist and management consultant, Dr. Shaywitz has experience in clinical drug development and strategic and commercial planning. Dr. Shaywitz is co-founder of the Center for Assessment Technology and Continuous Health (CATCH), a Boston-based initiative to use improved real-world measurement to improve care and drive science. He also is co-founder of the Harvard PASTEUR program, a translational research initiative at Harvard Medical School, and a founding advisor of Sage Bionetworks, a non-for-profit medical research initiative focused on open innovation. He works at a biopharmaceutical company in San Francisco; the views expressed in his postings are his own and do not represent the views of his employer. Dr. Shaywitz is an adjunct scholar at the American Enterprise Institute. His personal website is:

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