Why organized medicine needs to operate more like Google

“It is not the strongest of the species that survive, nor the most intelligent, but the ones most responsive to change,” Charles Darwin famously wrote.

Innovation has been the underpinning of American medicine for decades. However, as we move deeper into the 21^st century, it is important to assess whether we are providing an environment where a culture of innovation can thrive. 

The national landscape

Many have questioned whether the United States is losing its scientific edge. The World Economic Forum ranks the U.S. 48^th in the quality of math and science education. In 2009, for the first time, over half of U.S. patents were awarded to non-U.S. companies. Seventy percent of engineers with PhDs who graduate from U.S. universities are foreign born, according to a 2011 article in Forbes.

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In his book, “Innovation Nation,” John Kao points out that Chinese high school students must successfully complete mandatory courses in biology, chemistry, physics, algebra, and geometry before they graduate. In contrast, 40% of U.S. high school students take no science beyond introductory biology, Kao writes.

These data suggest that many U.S. physicians, by the time they start medical school or residency, are already behind in their math and science background compared to many of their foreign counterparts.

NEXT: Lessons from Google

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Lessons from Google

Although there have been significant changes in medical school curricula, there are as many or more similarities to the changes in curricula called for in the Flexner Report of a century ago as there are differences. Granted, there is an enormous knowledge base that has to be acquired in medical school, but training in how to think creatively is largely neglected. In their book “How Google Works,” Eric Schmidt and Jonathan Rosenberg make the distinction between “knowledge workers,” which would describe most medical students and physicians, and “smart creatives” who embody technical knowledge with creativity. They further state that “smart creatives” are the key to organizational success in the Internet Century.

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There are other lessons to be learned from Google. The medical profession is flush with hierarchy from freshman to senior year in medical school, from intern to chief resident, from instructor to full professor. Although experience and authority has its place in medicine, particularly in surgery, we need to alter the surgical culture in many ways. Relative lack of hierarchy has translated into a culture of innovation for Google. The new hire is not reluctant to challenge his seasoned manager about an idea or design. How often have any of us seen an intern challenge the statement of a chief resident, much less that of a full professor? Google refers to its more egalitarian environment as a “flat” organization.

Culture change

Culture change does not come easily for most organizations or professions. It is clear, however, that organized medicine must evolve into a more innovative culture if we are to prosper in the 21^st century. It has to start as early as grammar school and high school with an underpinning of more comprehensive math and science training. It should continue throughout undergraduate and medical school training. Medical schools should learn from business schools to design more of medical education around teams and team learning. Greater emphasis should be placed on a multidisciplinary approach to diagnosis and treatment.

Many urology residency training programs are now placing greater reliance on cross-specialty training. Rotations on gynecology and plastic surgery as well as other appropriate specialties should continue to grow and to be encouraged.

Medical schools and hospitals have to think creatively about how to encourage and support more multidisciplinary research efforts. We should encourage organizational designs that are more “flat” than “vertical.”

NEXT: The academic health center's role

The academic health center’s role

Traditionally, academic health centers (AHCs) and the National Institutes of Health have been the epicenters of medical research. However, both are facing daunting challenges as we look to the future.

Dzau et al have identified some of the unique challenges facing academic health centers, particularly in regard to innovative research (N Engl J Med 2013; 369:991-3). They comment that the current cost of research often exceeds the “soft money” available and for each dollar of direct federal support, and an additional 30 to 40 cents is needed from institutional resources. They warn about a “margin meltdown” or a growing gap between research costs and available funds to AHCs. They urge AHCs to become more selective in areas in which they focus, which again requires greater collaboration and less hierarchy to support innovative science.

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Another lesson is that innovation is not innate. It can be taught. Roberta Ness, MD, MPH, dean of the School of Public Health at the University of Texas at Houston, outlines four stages of teaching innovative thinking:

• overcoming barriers to creativity

• providing methods for thinking “out of the box”

• addressing individual and group dynamics

• allowing students to practice using these innovation tools (Acad Med 2011; 86:1201-3).

Teaching innovation has to become the charge of medical schools and residency programs with both resources and time devoted to it.

Many AHCs are driven by annual budgets and cost centers. To promote innovation, that mind-set has to be modified. Budgets are designed and measured, to a large degree, by short-term results. However, for innovation to thrive, long-term results must be valued as much or more as short-term goals. It is reasonable to speculate that the most successful AHCs of the future will be those that create environments where long-term research goals are valued and supported.

NEXT: The federal contribution

The federal contribution

As the deficit crisis has intensified, NIH funding has become increasingly challenging. In 1979, the NIH grant application success rate was about 40%. It is now less than half that. There is no immediate funding relief on the horizon. The public rarely reacts to short-term research funding cuts, leaving the executive and legislative branches comfortable with decreased research support that is unlikely to have any political consequences.

Nonetheless, there is some cause for optimism. Sen. Elizabeth Warren (D-MA) is introducing the Medical Innovation Act, which would increase NIH funding by siphoning a percentage of profits from pharmaceutical companies when they violate laws. Thirty national and local medical associations have endorsed the plan. However, the ultimate success of the bill is uncertain.

The clinician’s role

Practicing physicians should be aware that research is not some abstract endeavor that only exists in the domain of academic medical centers. Research applications touch clinical urologic practice in a palpable way every day. Every area of urologic practice has benefited from bench science. The clinician can support research funding by participating in political advocacy and enlisting his/her patients to participate in philanthropy. Given the reality of decreased federal funding constraints, private philanthropy is likely to be even more important in the near future.

Conclusion

The underpinning of innovation starts in secondary school or earlier and continues through university and medical training. As a profession, we should learn from Google and commit to rethinking some of our training and research paradigms to create an environment where innovation thrives.

The 20^th century has been called the American Century. The success of our nation and our medical profession were intertwined. There is no doubt this interdependence will continue. In his 2011 State of the Union address, President Obama said, “The first step in winning the future is encouraging American innovation.”

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