How Else can Innovation Come to Stagnant Markets?

We’ve been discussing creative destruction theories and come to the conclusion that no matter what theory you use, there is not the proper condition for a paradigm shift in medical education. For those of us who feel that a paradigm shift in the process of medical education would be a good thing, this is indeed bad news. It means that creative destruction can’t and won’t happen. The “Normal Science” of medical education will continue unabated and unchallenged until a recession in the health care market takes place. And if the latter theory is true, destruction will only occur on the upswing AFTER the downturn. And ONLY if the recession is so bad that it instills fear that another will come. It sounds hopeless.

Perhaps other factors that enable creative destruction can take hold, say, competition. Think digital cameras from Canon and Nikon vs. the old film based ones from Kodak (which by the way had digital technology that it chose not to use). Competition pushed creative destruction. Medical schools sadly don’t compete with each other. No hope there. Strike 1.

How about unstable labor markets? A stable labor market discourages creative destruction as people stay with what they have and few are incentivized to become entrepreneurs. Although there has been some upheaval in term of PhDs at medical schools most jobs are pretty secure. That security translates again to less anxiety and less interest in and support for creative destruction. Another dead end. Strike 2.

Excess regulation inhibits creative destruction. Examples include cities that are trying to halt AirBNB and Uber with laws that were written 50 years ago, or laws that require Tesla to use dealerships. Medical education is so controlled by government regulations (OSHA, HIPAA, access rules) and systematized by non-governmental organizations that it is indeed highly regulated. Can it be that the original paradigm shift that started with the Flexner Report is now part of the problem? That is, in seeking “consistency” and “quality” we created a system that highlights banality, caution, and a lack of innovation? We thus squelched creative destruction in the process just as is seen in markets with excessive government regulation. Is the solution then to loosen standards and dissolve organizational bodies so that schools (like states in the US) can be incubators or novel ideas? Since institutions come but rarely go, this seems rather unlikely. Strike 3.


The depressing conclusion (for folks who want change to happen) is that the “creative destruction” model is stymied from action because of: 1) lack of a downturn [2 weeks ago blog], 2) lack of a fear of a downturn because of incessant growth and easy access to money [last week’s blog], and 3), no competition, a comfortable and stable labor market, and tight regulation [this week’s blog].

It makes sense. But it’s depressing nonetheless that the environment for creative destruction and subsequent paradigm shift in medical education is extremely poor.

Let the Good Times Destruct the Status Quo

Last week I described a theory that creative destruction happens because of downturns that spur new solutions, and the lack of a downturn in the health economy is why medical education is stagnant.
An alternative model found that in fact creative destruction happens during periods of growth not recession. Think of the dot com bubble that spawned the most successful company, Google. Facebook too launched in a time of plenty. Uber arrived after the crisis of 2008 was over and has been on a tear ever sense. And now Uber is the leader in driverless cars and trucks. So an abundant IPO and M&A environment that is full of resources spawns even more opportunities for creative destruction.

Certainly health care has done nothing but grow and in several markets (e.g., Pittsburgh and UPMC) consolidation and integration and rapid growth are pretty obvious. With all that money sloshing around it should have led to enormous opportunities for creative destruction. Sure medical schools have replaced dark depressing lecture halls with windowed learning environments full of round tables and projectors. And others have built huge simulation centers with mannequins and rooms for standardized patients. But if one contrasts that with the growth of Apple and the impact of the iPhone or Google and search, it’s clear that the enormous riches of healthcare (17% of GNP and growing) haven’t translated to enormous change.

Why not?

Perhaps paranoia and fear of a recession is really the key. A history of a growth period following a recession would include a sense of anxiety (i.e, “we’ve got to be ready!”) about the potential for another recession. Without a past recession (such as we had in 2008 for real estate especially and other markets but not health care) there is no anxiety going forward. So easy or constrained flow of money is not the key to creative destruction. Money just enables such destruction when combined with anxiety about being ready to weather the next storm. And thus with medical schools and their hospitals as the top revenue generation for universities, and hospital CEOs and VPs among the highest paid executives in universities, there is little need for the health care industry to worry that the days of growth are coming to an end. And thus little reason to be hopeful that medical school education will change anytime soon.

So where is the Creative Destruction?

Assuming the existing paradigm of medical school education is tired and in need of replacement, the next question is why hasn’t it happened? Technology change is all around us. Students have replaced memorization and note cards with the EHRs, phones, laptops and Google. Yet the system is relatively unchanged. How come?

A review of creative destruction is helpful. The original theory of creative destruction (replacement of old with new) was that downturns in the economy spurred such destruction. This “liquidation model” proposed that when things go bad people revisit resource allocation and come up with novel solutions. The application of this model to medicine would infer that the unending growth and riches of healthcare is the problem. Additionally the ability to dump more and more debt onto medical students [thus forcing students to choose high paid specialties focusing on procedures] has further enhanced the riches of the industry. The end result of all this largesse is that the healthcare aspect of the economy has been protected from from the risks (and destructive value) of recession. Without downturn there is complacency and thus stagnation.

So for us to move out the current "Normal Science" and shift the paradigm we would then need something bad to happen in terms of health care. Now since health care is 17% of GDP you can argue either way.

Option #1: No way can that happen; our entire economy will crash.

Option #2: It is inevitable. How much longer can the US remain competitive when it spends twice what any other country spends and still does not provide health care to everyone?

I wish I had the magic ball to predict which one will win. Sadly, based on the above theory we lose either way. If everything stays rosy then medical student changes. If health care in the US crashes then medical student training changes but the system is in chaos.

The Paradigm Shift to Experiential Learning

In the discussion of innovation and paradigm shifts, it's helpful to review weaknesses in the process of challenging the existing paradigm. In this case, I am going to discuss the paradigm of a standard "academic" approach to education.

I recently got a chance to experience experiential learning first hand in a course called "Modern Marketing". The course eschewed the usual "academic" approach to education or the more trendy "case-based" approach to education. Instead it chose to teach modern marketing via participating in the Google Online Marketing Challenge (GOMC).

The experiential learning involved:

1. Reviewing potential team members
2. Contacting them about joining or adding them to a team
3. Setting up communication techniques
4. Defining strengths and roles
5. Forming a team contract to define team expectations
6. Identifying potential clients to work with the GOMC
7. Deciding as a team what client to solicit
8. Contacting clients
9. Forming an understanding to work with that client
10. Creating a contract that would define the expectations
11. Negotiating that contract

Before actually investigating the use of [Google Adword] marketing for a specific client's website.

Note that the above elements are team building/personal/business skills; these are not "marketing" skills. As we migrate from the old (e.g., boring, didactic, research, academic, expert-based) pedagogy in an attempt to confer skills/competencies vs. knowledge we must challenge our assumptions. In this case the assumption is that experiential learning is more effective and even if that effectiveness comes as a cost the value outweighs the cost.

I disagree. Inefficiency is inefficiency no matter how exciting the outcome. As we alter our pedagogy to become experiential we need to be aware of the potential inefficiencies in that approach and to aggressively counteract those inefficiencies. Otherwise our learners spend time doing something they are already skilled at.

For example, if Hertz required that anyone renting a car first go through Driver's Education, that would be an excellent idea for a young kid who never drove a car before and hasn't take that course. To require that for someone who has been driving for 20 years is silly. Similarly, in the marketing class experiential learning example above the above process is a useful learning lesson at the beginning of training (assuming such skills don't exist). But putting such a process at the beginning of every course is inefficient. Not assessing if these skills already exist is lazy.

Let's say we went back to the old pedagogy. In that case the first item would probably be "complete module 1 in the online course/book and answer the questions." Perhaps that wouldn't be trendy or impactful but efficient. But at least the first action in the course would be related to marketing.

What to do if you want to deploy more active, participatory experiential learning model?

In this case the solution is quite easy. Move efforts that are "core skills" to a module focusing on "core skills development." Then identify potential inefficiencies and root them out. In this case:

1. Assign team members to teams
2. Deploy an efficient communication framework to all teams and refine it (alas such a product probably does not exist thanks to lameness of Blackboard and Canvas) - Come on Google do it for us!
3. Pre select all companies to work with and ensure they have already agreed to participate and signed a contract to that extent.

Skills training/learning then occurs starting with the first hour of the first day.

As medical training moves to experiential learning it must put effort into similarly rooting out components that are unrelated to the skills development (i.e., competency creation) task at hand. And to not accept inefficiency as a necessary component of that the end goal.

So what is the core weakness in the process of challenging the paradigm? Caution. The old paradigm is alive and well in the above inefficient example. Inefficiency leads to frustration and confusion. It saps excitement and drives folks back to the old way of doing things. Most importantly it ensure that it doesn't work that well. It's a classic example of, "I want to challenge but not alter". As I interpret Kuhn, the existing paradigm is a wall and to some extend we don't want to break it down for fear of what is on the other side. I'll avoid putting in Reagan's quote to Gorbachev.

Micro Shifts

I'm at the Winter Conference on Brain Research (WCBR) which is full of very complicated talks about brain functioning and the underpinning mechanisms and mediators. It's Kuhn's "Normal Science" writ large. But since Kuhn focused on physics and it was 50 years ago how could he have imagined such a huge effort focused on such a small (comparatively) problem? 

Were he to be at this conference, perhaps he would have identified "Micro-Paradigm Shifts" that follow the same pattern but are limited to a smaller field. As an example genetics is slowly challenging the Bipolar Disorder I/Schizoaffective/Schizophrenia rubric and imply they are all the same. Most people say it's bunk and others simply carry along with DSM-V and ignore the debate and implications. But if these diagnostic categories are wrong then the entire field of psychiatry has been traveling down the wrong path (and misdiagnosing patients and potentially mistreating them) for eons. Certainly that would qualify for a paradigm shift.

Similarly there is probably some finding at this conference which is "upsetting" to some attendees and challenges the known order. Perhaps what we really need is a way to identify the early stages of shift where/when someone challenges "normal science."

In terms of medical student training we might look for evidence of unease. For example, the emphasis of the "new" topics (economics, big data, data analysis, communication, coordination) isn't really causing any unease. Annoyance, frustration and perhaps irritation for some, but certainly not unease. So this is still "normal science" of medical education. It's just adding topics already to crowded curriculum (which lacks coherency, recognition of unsustainability, or relevance to the actual practice of medicine - but I digress.)

In contrast arguments that medical school should be reduced to 3 years (which I find compelling) have been greeted with unease. So any challenge to the "medical school takes 4 years" paradigm [Duke's replacement of one year with a research year seems a sneaky way of implementing change without causing unease] would seems to be evidence that a shift is happening. The actual shift may not be to 3 years. It may be to an entirely new approach (distance learning, individualized curricula, varying lengths?) to medical school training. But to me identifying unease is the key to identifying potential shifts, and changes to the 4 year plan are about the only change that I see that causes unease.