2014 Association of American Physicians Presidential Address. Disruptive innovation as a driver of science and medicine.

Academic medicine is an ecosystem. Like any ecosystem, critical factors affecting sustainability include diversity, disruptive external forces, and natural selection. Perhaps the most important issue we must grapple with is the extent to which we can proactively shape the future of academic medicine versus being subject to the natural forces of change. In thinking about this question, I am reminded of a quote from Ludwig van Beethoven in response to circumstances beyond his control. Faced with impending deafness, Beethoven said, “I shall seize fate by the throat; it shall certainly not bend and crush me completely” (1). Like Beethoven, the leaders in academic medicine should not only be resilient, but we have an obligation to society to identify creative solutions so that we can fulfill the AAP mission, as stated by Sir William Osler in 1885, “to advance scientific and practical medicine” (2). Never before have we had such advanced tools and the fund of knowledge to solve the ills of society. Indeed, Osler would be stunned to see the resources available to us. Today, I want to address the role of disruptive innovation in science and medicine. In doing so, I will provide examples of disruptive innovation that has had lasting impact on society, attempt to predict where future disruption may occur, and suggest how we may play a more active role in shaping our future. Some of what I say, you would expect to hear from a physicianscientist and President of the AAP; some of my message, I hope, will surprise you. Long before Clayton Christensen, a Professor at the Harvard Business School, coined the term “disruptive innovation,” I experienced the compelling forces that underpin this idea (3). When I was an undergraduate student, a biochemistry professor introduced me to the concept of “affinity chromatography,” a means to purify proteins by using their substrates or ligands to bind them to columns during chromatography (4). The yields were remarkable — it was a technology that I found elegant in its design, logic, and simplicity. Inspired by this technique, I joined the research group of Pedro Cuatrecasas, one of the pioneers of affinity chromatography. My subsequent PhD work occurred in the late 1970s and involved protein biochemistry and enzymology, work that I loved even though half my life was spent in the cold room. Near the end of my PhD work, a journal club presentation exposed me to something even more exciting — the expression of recombinant somatostatin in bacteria (5). I had an eerie feeling that the traditional biochemistry skills I had learned were about to be eclipsed. Contemplating how this new finding may impact future research, a chance encounter during my third-year clerkship with the pediatric endocrinologist Jud Van Wyk opened up a new path. At the time, Jud was concerned about the shortages of human growth hormone (hGH), the only treatment for children with growth-hormone deficiency. Human cadaveric pituitaries had been found to transmit Creutzfeldt-Jakob disease, ultimately leading to a ban on hGH (6, 7). I told him about the experiment to produce recombinant somatostatin and suggested that it might be possible to produce hGH using this approach. Jud charged me to learn recombinant DNA technology as a means to participate in this biologic revolution. With a little homework, I learned that endocrinologists at the Massachusetts General Hospital were collaborating with groups at MIT to introduce recombinant DNA technology into the field of endocrinology. I was fortunate enough to join them and immediately embraced this exciting field. The production of hGH using recombinant technology was ultimately accomplished in about 1980, circumventing our reliance on human tissue (8). This experience with the impact of recombinant DNA technology was a second example of a transformative disruptive technology in my young career. However, chance encounters may not always create opportunities. Thus, we must be proactive in structuring ecosystems that cultivate innovation and allow us to recognize these paradigm shifts and harness them to solve problems. History is replete with examples of disruptive innovation, dating back to ancient times. Examples include the compass, the printing press, currency, gunpowder, and many others (9). As noted above, Clayton Christensen has more formally developed the concept of disruptive innovation as a major force of change in business, education, and health care. The general concept is that companies or industries face what has been termed the “innovator’s dilemma” in that they are conflicted in response to a potential game-changing disruptive technology (3). This dilemma occurs because newer, and often cheaper, technologies threaten more profitable, sustaining innovations, making it difficult to substitute the newer technologies for the products that are generating the margins of today. These ideas are developed in his book, The Innovator’s Dilemma, and subsequent books and articles, including, “Will disruptive innovations cure health care?” (3, 10). Imagine that you are Kodak, a company based largely on film, and someone develops digital imaging, or that you are a mainframe computer company like IBM or DEC, and advances in processors lead to the development of inexpensive but powerful personal computers. In our own lives, we recognize how cable or satellite TV has displaced air antennas and how cell phones have displaced landlines. E-mail, the successor to conversations, is now threatened by texting. News has moved from print to tablet to Twitter. These types of disruptive innovations focus largely on technology. However, other powerful disruptive forces might also be Conflict of interest: The author has declared that no conflict of interest exists.