written about the most unusual cases of disease known to man, not the common
medical conditions upon which most of medical care is based. Internists
leave their medical center training sites having not been exposed to a single case
of osteoarthritis, early-stage diabetes or allergic asthma; never having examined
a normal geriatric patient versus such a patient close to death, or a rural farmworker
suffering from exposure to herbicides. These kinds of patients do not
visit the academic medical center. Ironically, the knowledge and skills required
to treat these kinds of common medical problems are specialized, yet this knowledge
is not the focus of medical education in the late 20th century.
In an article from the New England Journal of Medicine titled “The Ecology
of Medical Care,” written by a group of researchers in the departments of
Preventative Medicine, Medicine and Biostatistics at the University of North
Carolina, the following is reported:
• In a population of 1,000 adults (age 16 or older), 750 will experience an
episode of illness in a particular month;
• Of these, 250 will consult a physician;
• 9 of these will be hospitalized;
• And 1 will be referred to a university medical center.
The focus of medical textbooks is that 1 case (in the metaphorical sense) that
makes it to the university medical center. The year the article was written was
1961 (NEJM, 1961, 265:885). The focus of medical education in academic
medical centers today is largely the same.
In his book The Innovator’s Dilemma (1998, Harvard University Press),
Clayton Christensen describes the forces against change in established corporate
structures. Using examples from corporate America, he illustrates how innovation
almost always comes from outside a corporate structure, from what he calls
disruptive technology. The values, the culture, the way decisions are made within
the established corporate institution producing the sustaining technology in a
field make it impossible for that institution to change quickly enough to meet
the demand of customers for change.
The ability of academic medical centers to meet the need for educational
reform can be examined using this paradigm. Their product, medical care, is
ever more technically driven, and the performance of their product is needed
by an ever smaller group of patients (those with the rarest diseases not treatable
anywhere else). Meanwhile the mainstream customers (patients) have needs that
are very different from this rarefied set of the most demanding customers. The
resulting situation we find today sets up beautifully a platform for launching
the development of a disruptive technology, a new approach to medical education
and health care delivery. This disruptive technology would embody different
values, build a new culture and succeed where the sustaining technology fails
because the disruptive technology is unencumbered by the culture of the sustaining
technology, which values only the research contributions to the health of
40 | Breaking the Mold